Citation Nr: 21003529 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 17-02 477 DATE: January 21, 2021 REMANDED Entitlement to service connection for a thoracolumbar spine disorder is remanded. Entitlement to service connection for radiculopathy of the right lower extremity, to include as secondary to a thoracolumbar spine disorder, is remanded. Entitlement to service connection for a cervical spine disorder, to include as secondary to a thoracolumbar spine disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2003 to March 2004. This matter comes to the Board of Veterans’ Appeal (Board) on appeal from an April 2012 rating decision of the Department of Veteran’s Affairs (VA) Regional Office (RO) in Portland, Oregon. In October 2019, the Veteran presented testimony in a travel board hearing before the undersigned Veterans Law Judge. The appeal was previously remanded in January 2020 for additional development. It has since been returned to the Board for further appellate consideration. In a September 2020 rating decision, the RO granted service connection for a right ankle disorder. Thus, this issue is no longer on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). 1. Entitlement to service connection for a lumbar spine disorder Remand is required for an adequate examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Remand is required for an adequate VA etiological opinion. In a December 2016 VA examination, the examiner acknowledged the Veteran’s STRs indicating back pain after his deployment, but provided a negative nexus opinion, noting a lack of treatment for the back until 7 years after separation from service. But private treatment records in December 2005, less than two years from service discharge, note that the Veteran reported chronic episodic back pain. Thoracic spine strain was diagnosed. Thus, the examiner used inaccurate evidence to support the negative nexus opinion. 2. Entitlement to service connection for radiculopathy of the right lower extremity This issue must be remanded as it is inextricably intertwined with the issue of entitlement ot service connection for a thoracolumbar spine disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). In a December 2016 VA examination, the examiner diagnosed radiculopathy in the lower right extremity due to involvement with the sciatic nerve and associated with the thoracolumbar spine disability. Accordingly, it is intertwined with the resolution of that issue. 3. Entitlement to service connection for a cervical spine disorder, to include as secondary to a thoracolumbar spine disorder, is remanded. Remand is required for an adequate VA etiological opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Veteran received a VA examination in August 2020. The examiner opined the Veteran’s cervical spine disorder was less likely than not incurred in or caused by active service, explaining that there was no medical evidence in service documenting that the Veteran was documented for a neck complaint. The examiner acknowledged the buddy statements and statement from the Veteran’s wife describing the Veteran’s strenuous duties while in service and a buddy statement corroborating the Veteran’s description of a rear end accident. The examiner however, concluded the lack of evidence suggest if the Veteran was experiencing neck symptoms while on active duty and after discharge, they were minor in level. The Board finds that the opinion is inadequate as the examiner did not address aggravation and also did not explain why minor symptoms during and after service could not support a finding of service connection. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the lumbar spine disorder. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the lumbar spine disorder had onset in, or is otherwise related to, active service. The examiner must address the following: 1) the Veteran’s MOS as a bridge crewmember, including his October 2019 Board hearing testimony describing wearing body armor and carrying gear; 2) buddy statements corroborating the heavy duties of the Veteran’s MOS; 3) the October 2019 buddy statement describing that the Veteran was involved in a truck accident while in service; 4) the December 2016 VA examination; and 5) the December 2005 record noting the Veteran reported chronic episodic back pain. 2. Obtain an addendum opinion regarding the etiology of his cervical spine disorder. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed cervical spine disorder or cervical spine pain that caused functional impairment of earning capacity had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed cervical spine disorder or cervical spine pain that caused functional impairment of earning capacity was caused or aggravated by the thoracolumbar spine disorder. The examiner must address the following: 1) Veteran’s lay statements regarding cervical spine pain; 2) the buddy statement from N.S describing the in-service rear in accident ; 3) the buddy statements corroborating the his duties in his MOS as a bridge crewmember; and 4) the August 2020 VA examination and opinion. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Braxton, 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.