Citation Nr: 21005211 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 15-02 644 DATE: January 29, 2021 REMANDED Entitlement to service connection for a lumbar spine disability, diagnosed as spondylolysis, isthmic spondylolisthesis, spinal bifida, and exaggeration of the normal lumbar lordosis, is remanded. REASONS FOR REMAND The Veteran had active service from July 1971 to July 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2017, the Veteran testified at a videoconference hearing held before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the electronic record. In May 2018, the Board reopened the claim of entitlement to service connection for a low back disability and remanded it for further development. In June 2020, the Board remanded the claim again for further development. An October 2019 VA examination report reveals diagnoses of spondylolysis, isthmic spondylolisthesis, and exaggeration of the normal lumbar lordosis. July 1992 VA X-rays show spinal bifida of S1. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the claim on appeal includes all lumbar spine disabilities. In June 2020, the Board remanded the claim for an addendum opinion to determine whether the isthmic spondylolisthesis is a congenital defect, congenital disease, or other type of disability. The August 2020 VA medical opinion report does not adequately address the nature of the isthmic spondylolisthesis. Therefore, the RO did not comply with the directives of the June 2020 remand. Stegall v. West, 11 Vet. App. 268 (1998). Another addendum to the VA examination is necessary. The Veteran’s three DD Form 214s of record reflect that he had active service from July 1971 to July 1991. Other than a July 1971 entrance examination that is located in service personnel records, there are no service treatment records for the period of service from July 1974 to August 1974. Given that the request for service treatment records did not show a prior period of active service from July 1971 to August 1974, the RO should again attempt to obtain service treatment records from the first three years of service. The RO should also obtain any additional records from the South Texas Veterans Health Care System for the period from October 2020 to the present. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for his low back disability and obtain any identified records. Obtain the Veteran’s VA treatment records from the South Texas Veterans Health Care System for the period from October 2020 to the present. 2. Obtain the Veteran’s complete service treatment records for his period of active service from July 1971 to July 1991. 3. After the development in 1 and 2 is completed, the RO should arrange for the Veteran’s electronic claims file to be reviewed by the VA examiner who prepared the August 2020 VA medical opinion for the preparation of an addendum regarding the nature of lumbar spine disability. If that examiner is unavailable, arrange for the claims file to be reviewed by another medical professional. The Veteran should only be scheduled for another examination if the new medical professional deems it necessary. The clinician must opine on whether it is more likely than not (probability of greater than 50 percent) that the spondylolysis is a congenital or development defect. If the spondylolysis is a congenital or development defect, the clinician should opine on whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran now has additional disability due to an in-service disease or injury superimposed upon such defect If the spondylolysis is not a congenital or development defect, the clinician must opine on whether it is clear and unmistakable (undebatable) that the spondylolysis preexisted the Veteran’s service. If the clinician finds the spondylolysis did clearly and unmistakably (undebatably) preexist service, the examiner must opine whether it is clear and unmistakable (undebatable) that the spondylolysis was not aggravated by service. If the clinician finds that the spondylolysis did not clearly and unmistakably preexist service, the clinician must opine whether it is at least as likely as not that the spondylolysis is related to an in-service injury, event, or disease, including the in-service low back treatment. The clinician must opine on whether it is more likely than not that the isthmic spondylolisthesis is a congenital or development defect. If the isthmic spondylolisthesis is a congenital or development defect, the clinician should opine on whether it is at least as likely as not that the Veteran now has additional disability due to an in-service disease or injury superimposed upon such defect If the isthmic spondylolisthesis is not a congenital or development defect, the clinician must opine on whether it is clear and unmistakable (undebatable) that the isthmic spondylolisthesis preexisted the Veteran’s service. If the clinician finds the isthmic spondylolisthesis did clearly and unmistakably (undebatably) preexist service, the clinician must opine whether it is clear and unmistakable (undebatable) that the isthmic spondylolisthesis was not aggravated by service. If the clinician finds that the isthmic spondylolisthesis did not clearly and unmistakably preexist service, the clinician must opine whether it is at least as likely as not that the isthmic spondylolisthesis is related to an in-service injury, event, or disease, including the in-service low back treatment. The clinician must opine on whether it is more likely than not that the spinal bifida of S1 found on July 1992 VA X-rays is a congenital or development defect. If the spinal bifida of S1 is a congenital or development defect, the clinician should opine on whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran now has additional disability due to an in-service disease or injury superimposed upon such defect If the spinal bifida of S1 is not a congenital or development defect, the clinician must opine on whether it is clear and unmistakable (undebatable) that the spinal bifida of S1 preexisted the Veteran’s service. If the clinician finds the spinal bifida of S1 did clearly and unmistakably (undebatably) preexist service, the clinician must opine whether it is clear and unmistakable (undebatable) that the spinal bifida of S1 was not aggravated by service. If the clinician finds that the spinal bifida of S1 did not clearly and unmistakably preexist service, the clinician must opine whether it is at least as likely as not that the spinal bifida of S1 is related to an in-service injury, event, or disease, including the in-service low back treatment. For the exaggeration of the normal lumbar lordosis and any other current lumbar spine disability, the clinician must opine whether it is at least as likely as not that the exaggeration of the normal lumbar lordosis and any other current lumbar spine disability are related to an in-service injury, event, or disease, including the in-service low back treatment. 4. After development above has been completed, the RO should readjudicate the Veteran’s claim. If the claim remains denied, the Veteran should be issued a supplemental statement of the case, with a copy to his representative, and afforded an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Cherry, 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.