Citation Nr: 21001942 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-32 307 DATE: January 12, 2021 REMANDED Entitlement to service connection for a low back disability, to include disc degeneration, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to August 1972. This case comes to the Department of Veterans Affairs (VA) Board of Veterans’ Appeals (Board) on appeal from an Agency of Original Jurisdiction (AOJ) rating decision dated in May 2013. This case was most recently remanded by the Board in July 2020. Unfortunately, for the reasons set forth below, another remand is necessary. 1. Entitlement to service connection for a low back disability, to include disc degeneration is remanded. The AOJ obtained opinions regarding the etiology of the Veteran’s back disabilities in September 2012, March 2019, October 2019, and August 2020. As described in the Board’s August 2018 remand, the September 2012 opinion is inadequate. The remaining VA opinions are contradictory and contain conflictual information, making another remand necessary. In March 2019, a VA examiner reviewed outpatient records wherein in June 2012, Dr. D.D. indicated “it is possible that from this [helicopter] incident, [the Veteran] was predisposed to more rapid degenerative changes.” The examiner disagreed with this conclusion based on lack of documentation. In October 2019, a VA examiner indicated that a helicopter crash “does increase his risk of both arthritis and spondylitis from trauma.” However, the October 2019 examiner explained that “by history alone, his back pain is different from his current symptoms,” and without proper therapy, the Veteran’s symptoms would have likely worsened after service. All VA opinions of record are negative nexus opinions. However, the examinations improperly rely on lack of documentation, and do not adequately use medical principles to explain why the Veteran’s current presentation is not attributable to service. The October 2019 opinion, for example, does not explain how the Veteran’s back pain during and after service is different from his current symptoms when the Veteran reports current back pain. Nor does the examiner explain how he concluded there was no continuity of symptomatology when he explained the symptoms would have likely worsened after service. The March 2019 examiner relied upon literature to explain that there is a causal relationship between the Veteran’s obesity and osteoarthritis. However, the examiner did not specifically address all diagnoses, which includes ankylosing spondylitis, lumbosacral strain, degenerative joint disease, degenerative disc disease, anterolisthesis, diffuse facet arthrosis, and spinal stenosis. Finally, following the Board’s July 2020 remand, an examiner opined in August 2020 that the Veteran’s service-connected pilonidal cyst did not proximately cause his back disability. The section on the Disability Benefits Questionnaire regarding “Medical opinion for aggravation of a nonservice connected condition by a service-connected condition (Section VI)” was left blank although in Section VII, the examiner stated in answer to a later question of proximate cause and aggravation that the Veteran’s pilonidal cyst is unlikely to have any “direct impact” on any of the Veteran’s back conditions. It is unclear whether this rationale goes to the question of aggravation in light of the lack of response in the earlier section. Therefore, on remand, the examiner will have the opportunity to provide further opinion on the question of aggravation. The matters are REMANDED for the following action: 1. Forward the record including a copy of this remand to a suitably qualified examiner for completion of an addendum opinion. Following review of the record, to include the August 2018 remand and the current Board remand, the examiner should respond to the inquiry below. (a.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s back disability, to include ankylosing spondylitis, lumbosacral strain, degenerative joint disease, degenerative disc disease, anterolisthesis, diffuse facet arthrosis, and spinal stenosis, is etiologically related to, incurred in, or caused by the Veteran’s military active service, including a helicopter crash. (b.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s arthritis manifested within a year of separation from service. (c.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s back disability, to include ankylosing spondylitis, lumbosacral strain, degenerative joint disease, degenerative disc disease, anterolisthesis, diffuse facet arthrosis, and spinal stenosis, is aggravated by the Veteran’s service-connected pilonidal cyst residuals. (d.) In providing the above opinions, the examiner should address and consider the following: all the Veteran’s diagnoses of record, including ankylosing spondylitis, lumbosacral strain, degenerative joint disease, degenerative disc disease, anterolisthesis, diffuse facet arthrosis, and spinal stenosis; Dr. D’s June 2012 statement that the Veteran was predisposed to more rapid degeneration from a helicopter crash; the Veteran’s report of onset of symptoms in 1968, and that they have gotten progressively worse since; the Veteran’s argument that severity of pain and years of treatment indicates an onset earlier than what was shown in the records; the Veteran’s contention that the helicopter crash exacerbated residuals from pilonidal cyst; and the October 2019 VA examiner’s conclusion that the Veteran likely had back strain or contusion from the crash, which would have worsened without treatment, and that trauma increases risk of arthritis and spondylitis. (Continued on the next page)   A complete explanation for all opinions expressed must be provided. A clearly stated rationale must not be based solely on lack of documentation or records. The reasons for any opinion must include a discussion of the relevant evidence. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Smith, Associate 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.