Citation Nr: 21000469 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-03 142 DATE: January 5, 2021 REMANDED Entitlement to service connection for a back disability, to include as secondary to service-connected bronchial asthma, is remanded. REASONS FOR REMAND The Veteran served from February 1969 to November 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision of a U.S. Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for a back disability. The appeal was previously before the Board in November 2016. At that time, the claim was remanded to schedule a requested video hearing. The appellant testified before the undersigned Veterans Law Judge at a May 2018 videoconference hearing. The appellant also testified before a decision review officer at an April 2015 hearing at the RO. Hearing transcripts for both hearings have been associated with the claims file and reviewed. In August 2018 this matter was remanded a second time for further development. Such has been completed and this matter has been returned for further consideration. Unfortunately, another remand is necessary despite the development undertaken to date. Although a November 2019 VA examination obtained pursuant to the remand adequately provided an unfavorable opinion regarding the question of whether a low back disability was caused or aggravated by his service connected bronchial asthma disability, further medical records have been received since the August 2018 remand that triggers the need for further revisiting the question of service connection on a direct basis. Of note, records from 2018 and 2019 show a diagnosis of lumbar spondylosis. This includes a June 2018 record diagnosing lumbar spondylosis when he was seen for chronic knee and back pain. This diagnosis was again given in November 2018 and July 2019 records when he was given lumbar injections. This post-service diagnosis was not shown at the time the Veteran underwent a VA examination in February 2013, when the examiner determined that his low back disability was not incurred in service, determining that the findings of lumbar stenosis shown in a MRI of the lumbar spine was unrelated to the findings of lumbar spondylosis shown in the STRs in 1970 and unrelated to the lifting injury to the back in service in 1970. The August 2012 MRI reviewed by the examiner showed severe lumbar stenosis at the L3-L5 levels with bilateral facet joint hypertrophy at L3-L4 L4-L5 and L5-S1. The Board does note that spondylosis was shown in a cervical spine MRI which ended at the top of the thoracic spine (T1) in November 2009. STRs repeatedly gave a diagnosis of spondylosis, including on X-ray in June 1970, and diagnosed again in August 1970 and March 1972. He also was noted to have injured his back while lifting in February 1970 and was diagnosed with back strain. One of the February 1970 records suggested the back pain had been present for 1 ½ years and triggered by lifting. The March 1972 record described him having a flareup of spondylosis. Given that the in-service spondylosis is once again shown to be a diagnosis, further review of the records and an addendum opinion is warranted to again address service connection on a direct basis that considers this new evidence showing this diagnosis. Additionally, the Board notes that the Veteran has provided lay evidence of continuity of symptoms per his hearing testimony of May 2018 in which he described having a lot of back pain after service for which he received treatment including medical and chiropractic treatment in the 1970s prior to a post service injury that required back surgery. He indicated that the records from the 1970s were unavailable. Transcript pg. 6-11. The February 2013 VA examiner did not have access to this lay evidence of continuity of symptoms and the November 2019 VA examination did not address direct service connection. In view of the foregoing, the Board finds that an addendum opinion is necessary to further address this complete evidence to include lay evidence of continuity of symptoms and the same post-service diagnosis of spondylosis shown as that in-service. Furthermore, the Board notes that although a back problem was not found or reported on entry in February 1969 , the STR of February 1970 suggesting a year and a half history of back pain would suggest that he had back pain prior to his entry in February 1969. Thus, an addendum opinion should additionally address whether the presumption of soundness was rebutted in this case. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s back disability, which now includes a diagnosis of spondylosis, is at least as likely as not related to service, including the inservice lifting injuries diagnosed in February 1970, a diagnosis of spondylosis noted in June 1970 and a flareup of spondylosis in 1972? The examiner should further address in light of the February 1970 record suggesting back pain of 1 ½ years duration (which would have been prior to service) whether a back disability clearly and unmistakably (undebatable) preexisted the Veteran’s service? If the examiner finds a back disability did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to service, including the in-service lifting injuries in 1970 and the flareup of spondylosis in 1972. All opinions should be accompanied by adequate rationale. The examiner should also discuss the lay evidence describing continued symptoms after service in addition to the medical evidence in the STRs and post service records. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Carol Eckart 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.