Citation Nr: 21063115 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-42 285 DATE: October 13, 2021 REMANDED Service connection for spinal degenerative disease is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1994 to February 1995, from September 2001 to May 2002, and from October 2002 to October 2003 in the U.S. Army with additional service in the Army Reserve and National Guard. This matter comes before the Board of Veterans' Appeals (Board) from a November 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. This matter was previously before the Board in October 2019, at which time the issue on appeal was remanded for additional development. Although further delay is regrettable, the Board finds that additional development is required before the Board can make a fully informed decision. At the outset, the Board notes that the Veteran's service treatment records (STRs) are incomplete. Notably, the Veteran's complete STRs from his last two periods of service are not of record. The Veteran's most recent DD Form 214 states that he was transferred to "HHD 785th Military Police Battalion Fraser, MI." Additionally, the Veteran reported that he was assigned to "IRR Control Group 1775 MP CO." In January 2008, the RO issued a Formal Finding on the Unavailability of Service Records; however, there is no indication that the RO requested records from all sources, including the Army Human Resources Command (HRC). The Board also notes that the Veteran retired from the Army Reserve in October 2007, after the RO requested the Veteran's records from various sources. Because this raises the possibility that the Veteran's service treatment and personnel records might have been held by his Reserve unit at the time the records were requested, and that those records might have moved after the Veteran's retirement, the Board finds that an additional attempt should be made to obtain these records. As such, the Board finds remand is necessary to further attempt to obtain outstanding STRs and service personnel records. The Veteran contends that his spinal degenerative disease is related to his active service or training while in the National Guard. See November 2013 Correspondence. He was afforded a VA examination in January 2020. The examiner opined that the Veteran's spinal degenerative disease is less likely than not related to an in-service injury, had its onset in service, or related to an injury, treatment, or accident in-service. The rationale stated that in reviewing the Veteran's in-service medical records, there was one note from June 1995 where he was seen for lower back pain and diagnosed with a muscle strain and was treated conservatively and no follow up was seen. The physician further stated that the Veteran served until 2003 and after service he worked in law enforcement until 2012. The physician concluded that the etiology of the Veteran's degenerative spine is at least as likely as not secondary to the normal aging process. The Board finds the January 2020 VA opinion inadequate for adjudication purposes because the physician did not adequately consider the Veteran's military and medical history. Additionally, the physician did not consider the Veteran's lay statements, including that he injured his spine during his last period of service. Moreover, the Board notes that the Veteran's complete STRs have not been obtained and the rationale was based on the lack of documentation of treatment for a lumbar spine disability during service. As such, the Board finds that remand is warranted to obtain an addendum VA medical opinion. Additionally, the Veteran also contends that his spinal degenerative disease is related to his service-connected right shoulder disability. The medical evidence of record also shows that the Veteran's lumbar spine disability may be related to his service-connected posttraumatic stress disorder (PTSD). However, the Board cannot make a fully-informed decision on the issue of service connection for spinal degenerative disease because no VA examiner has opined whether it is related to the Veteran's service connected right shoulder disability or PTSD. As such, this should be addressed on remand. The matter is REMANDED for the following action: 1. Contact the appropriate service department, the Army Human Resources Command (HRC), National Personnel Records Center (NPRC), and any other appropriate agency to obtain the Veteran's complete service treatment records and service personnel records for the dates of the Veteran's active duty, ACDUTRA, and INACDUTRA service, to include any records from his last unit assignment. The Board notes that the Veteran's DD Form 214 shows that the Veteran was transferred to "HHD 785th Military Police Battalion Fraser, MI" and the Veteran reported that he was assigned to "IRR Control Group 1775 MP CO." All actions to obtain the requested records should be fully documented in the record and any records or response(s) received should be associated with the claims file. If the records do not exist or further efforts to obtain the records would be futile, a formal determination must be made, pursuant to 38 C.F.R. § 3.159(c)(2), and a copy of such determination must be associated with the claims file and provided to the Veteran and his representative. 2. Thereafter, obtain an addendum opinion from an appropriate physician to determine the etiology of the Veteran's spinal degenerative disease. If an examination is deemed necessary by the physician, then one should be scheduled, and all necessary tests and studies should be completed. Upon review of the claims file, the physician is asked to opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's spinal degenerative disease had its onset in service. (b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's spinal degenerative disease is related to any in-service injury, event, or disease. (c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's spinal degenerative disease was (1) proximately due to or (2) aggravated by his service-connected posttraumatic stress disorder or right shoulder disability. A complete rationale must be provided for all opinions offered. If the physician cannot provide the required opinions without resorting to speculation, he or she shall provide a complete explanation as to why that is the case. Further, the physician must state whether the inability to provide the required opinions is based on a personal limitation or on a lack of knowledge among the medical community. (Continued on the next page) The physician should consider the lay statements of record, including the June 2007 Correspondence, November 2013 Correspondence, May 2014 Statement in Support of Claim, and the October 2021 Appellate Brief. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinion. The physician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kernen, 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.