Citation Nr: 21000162 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 18-20 343 DATE: January 4, 2021 ORDER Entitlement to service connection for low back disability, to include as secondary to service-connected cervical strain, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1965 to March 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2016 rating decision by a Department of Veterans Affairs Regional Office (RO). In May 2020, the Veteran testified at a Board videoconference hearing before the undersigned. In June 2020, the claim was remanded for further development. The Board notes that a claim for service connection for cervical spine disability was previously on appeal. However, in a November 2020 rating decision, the RO granted service connection for this disability. Accordingly, this claim is no longer on appeal before the Board. Entitlement to service connection for low back disability. The Veteran asserts that his current low back disability is related to service. The Veteran’s service treatment records show that at an initial November 1968 medical visit, the Veteran was complaining of stiffness in the neck and arm over the past 6 months with no antecedent trauma. There were no paresthesias and full range of motion and the diagnostic impression was probable chronic osteoarthritis. Subsequent November 1968 cervical spine X-rays showed displacement of the spinous process in C5-6-7. At his March 1969 separation examination, the Veteran was not found to have any low back problems. At a September 2020 VA contract examination, the examiner diagnosed the Veteran with lumbosacral strain. After examination and review of the claims file, the examiner concluded that the Veteran’s medical records supported a finding that the Veteran’s currently diagnosed cervical strain was at least as likely as not related to military service but that the Veteran’s diagnosed lumbosacral strain was less likely than not incurred in, caused by, or etiologically related to service. The examiner reasoned that the service treatment records documented the Veteran’s medical visit on November 4, 1968 for neck stiffness and the X-ray at that time documented significant abnormalities. The examiner opined that it was more likely than not that the Veteran’s back injury and now neck pain occurred during service. The x-ray findings would have led to chronic upper back and neck issues for him over an extended period of time. However, the medical records did not document or elaborate on a lower back condition during service. Although the most probative evidence of record does not indicate that the Veteran’s lumbosacral strain is directly related to service, it is unclear whether the evidence indicates that his now service-connected cervical strain may have caused or aggravated his lumbar spine disability. Therefore, the Board finds a remand is necessary for a clarifying opinion. The matter is REMANDED for the following action: Obtain an addendum to the September 2020 VA examination for the Veteran’s lumbar spine disability. The examiner should opine whether it is at least as likely as not that his service-connected cervical spine disability (1) caused or (2) aggravated his lumbar spine disability. The examiner should explain why or why not. The examiner’s attention is directed to the September 2020 VA examiner’s comment that it was more likely than not that the Veteran’s back injury and now neck pain occurred during service. The x-ray findings would have led to chronic upper back and neck issues for him over an extended period of time. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.