Citation Nr: 21004049 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 17-38 967 DATE: January 25, 2021 REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 2000 to March 2012. For her meritorious service, the Veteran was awarded (among other decorations) the Air Force Commendation Medal. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in November 2018. A transcript of that hearing has been added to the Veteran’s file. This matter was previously before the Board in May 2019 in which the Board remanded the matter for further development. 1. Entitlement to service connection for an upper back disability (neck disability) is remanded. 2. Entitlement to service connection for a lower back disability (low back disability) is remanded. The Veteran is seeking service connection for a low back disability and a neck disability (claimed as upper back). She contends her disabilities are related to carrying her military gear and it caused strain on her back. The Veteran also contends her back disabilities are related to a scooter accident in April 2010. The Veteran also reported she underwent a breast reduction surgery in-service due to back and neck pain but contends the pain continued after the surgery. The Veteran underwent VA examinations for her back disabilities in January 2020. The Veteran was diagnosed with a lumbosacral strain. The Veteran underwent a lumbar spine x-ray in January 2020 and the impression reflected no fracture, lesion, or malalignment. The results also reflected no significant spondylopathy or focal bone abnormality. The imaging further showed tiny marginal endplate spurts on the left lateral at T7-T8, but the VA examiner determined this finding to be doubtful of acute importance. The VA examiner concluded the Veteran’s lower back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated there were no back issues on her enlistment examination and stated that she was involved in a scooter accident but only complained of pain in her left wrist, knee, and foot. The VA examiner then concluded the evidence does not suggest a nexus between her lower back disability and service. The Veteran was diagnosed with a cervical strain at her January 2020 VA examination for her claimed upper back disability. The Veteran underwent a cervical spine x-ray and it reflected mild reversal of normal cervical lordosis. The results showed no malalignment and disc and facet joints were normal without narrowing or bone spurs. The results showed apparent narrowing of the left-sided neural foramina and stated it is probably projectional. No uncovertebral or facet joint hypertrophy shown to indicate that actual left foraminal narrowing to be present. The impression stated the cervical spine is well maintained. The VA examiner concluded it does not appear the Veteran’s cervical strain began in-service. The VA examiner referenced the Veteran’s scooter accident but noted the Veteran did not complain of neck issues. The VA examiner also stated the entrance examination did not indicate any neck issues. The VA examiner concluded the evidence of record does not suggest a nexus between the Veteran’s neck disability and her active service. The Board finds the January 2020 VA opinions regarding the Veteran’s claimed disabilities to be inadequate. The Veteran’s contentions were not discussed by the VA examiner. She contends the strain of carrying 30-50 pounds on her back daily caused her back and neck disabilities. The VA examiner referenced the scooter accident and noted she was only treated for her left wrist, knee, and foot. The VA examiner did not discuss the Veteran’s contentions regarding her military occupational specialty (MOS) in security where she was on her feet daily. Accordingly, an additional VA opinion is required. The matters are REMANDED for the following actions: Obtain an opinion from an appropriate examiner regarding the possible relationship to service of the Veteran’s claimed back and neck disabilities. The examiner is to review the Veteran’s claims file before offering the below requested opinion. If the examiner determines that the requested opinions can only be provided after examining the Veteran, then schedule the Veteran for an appropriate examination. Regardless of whether an examination is performed, the examiner is to state whether it is at least as likely as not that the Veteran’s current back and neck disabilities are related to or had their onset during her active service. In answering this question, the examiner must acknowledge and discuss the Veteran’s in-service scooter accident, as well as the statements the Veteran has made regarding the stress that her MOS placed on her back and neck. The examiner must also discuss the significance of the Veteran’s reports of suffering from back and neck pain in VA treatment records beginning in 2013. A complete rationale for all opinions must be provided. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Mouzakis, 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.