Citation Nr: 21002748 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 14-21 320 DATE: January 14, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Air Force from January 1986 to September 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). Historically, the Board notes that the claim originally denied in a December 1993 rating decision. In response to a request to reopen the claim, the RO denied reopening the claim in August 2012 because it found no new and material evidence had been submitted. The claim was reopened and remanded by the Board in December 2015. Following return to the Board, it was again remanded in March 2018 and February 2020 for further development. The claim is now before the Board for appellate review. The Board notes that in the February 2020 remand, the Board recharacterized the issue to include any back disorder rather than limiting the claim to service connection for a low back disorder. Regrettably, remand is necessary again for compliance with the February 2020 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the claim must be remanded for another VA examination and medical opinion. In the previous remand, the Agency of Original Jurisdiction (AOJ) was partly instructed to obtain an addendum opinion. The examiner was directed to provide a nexus opinion and consider the Veteran’s assertions that his back pain had an onset in service and had continued since that time. Moreover, the examiner was directed to consider numerous instances where the Veteran was evaluated and treated for back pain while in service. In a March 2020 addendum opinion, the examiner opined that it is less likely than not the current back pain was incurred in or caused by the claimed in service injury, event, or illness. She referenced a December 2012 MRI that showed minor degrees of disc bulge and facet arthropathy without stenosis. The examiner also noted the Veteran’s assertions concerning the onset of his pain in service. While she found they establish chronicity, she stated they did not qualify to determine etiology of the condition. Moreover, she indicated that service treatment records reveal a back injury from a motor vehicle accident in August 1992, which was also noted in his July 1993 separation examination, but no other complaints or treatment until 2012 (20 years later). Lastly, she found the current back condition was not pathologically related to any injury sustained in the motor vehicle accident or other back pain reported during service. Rather, she indicated that the current back condition is related to the Veteran’s degenerative arthritis of the lumbar spine, and related to the aging process. While the February 2020 examiner noted the Veteran’s assertions, she erroneously indicated there were no other instances or reports of back pain except for the notation of a motor vehicle accident in the July 1993 separation examination, and instances after service beginning in 2012. The examiner did not address the noted complaints of recurrent back pain since 1986, including those in August 1988, October 1992, and July 1993 service treatment records. Moreover, while the examiner indicated the current back pain is related to the Veteran’s diagnosed arthritis of the lumbar spine, she did not provide an opinion as to whether the arthritis is related to service, including the motor vehicle accident. For these reasons, remand is necessary for another VA examination and medical opinion. Lastly, the Board acknowledges the request in February 2020 for the AOJ to develop records containing evidence of service in Southwest Asia during the Gulf War. An official military personnel files request for additional records returned negative results. Therefore, the Board finds the RO complied with the directive to attempt to obtain records to verify service in Southwest Asis during the Gulf War. The matters are REMANDED for the following action: The AOJ should schedule the Veteran for a VA examination to determine the nature and etiology of any back disorder that may be present by an examiner who has not previously examined the Veteran. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note the Veteran is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not the Veteran has a current back disorder, to include arthritis, that is related to his military service, including any injury or symptomatology and motor vehicle therein. The examiner should specifically consider the Veteran’s assertion that his back pain began in service and has persisted ever since. The examiner should also consider and specifically address Veteran’s service treatment records that show complaints of occasional low back pain of one-year duration in June 1988, following a complaint of mid low lumbar spasms. Also, in August 1988, he was involved in a motor vehicle accident and sustained a lower back strain. Additionally, in October 1992, he complained of low back pain after shoveling snow. Finally, the examiner should note that in his July 1993 separation Report of Medical History, the Veteran endorsed recurrent back pain since his in-service motor vehicle accident. The examiner should also address if the current diagnosis of arthritis of the lumbar spine is related to the Veteran’s diagnosed in-service lower back strain. In rendering the opinion, the examiner should discuss how any current back disorder generally presents or develops in most cases. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board.. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.