Citation Nr: 21072897 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 19-06 296A DATE: December 6, 2021 REMANDED Entitlement to service connection for a low back condition and mid back condition, also claimed as mid and low back injury to include associated radiculopathy (back condition), is remanded. Entitlement to service connection for diverticulitis, to include as secondary to irritable bowel syndrome (IBS), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1984 to July 1988 and from December 2005 to June 2007, with additional service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2014 and September 2017 Department of Veterans Affairs (VA) rating decisions. (The September 2017 rating decision also denied the issue of entitlement to service connection for migraine headaches and the Veteran properly appealed. A February 2019 rating decision granted service connection for migraine headaches.) In October 2020 correspondence, the Board granted the Veteran's representative's request for a 90-day extension to submit additional evidence and argument. 1. Entitlement to service connection for a back condition is remanded. The Veteran and his representative have set forth a direct theory for entitlement to service connection for his back disability. They contend that his back disability is related to a March 2006 in-service lifting injury. In a March 2014 statement in support of claim, the Veteran reported that the same accident that caused his service-connected hernia during service also caused his back disability. Based upon this report, the VA regional office ordered a VA examination to address a theory of secondary causation. During an October 2014 VA (back) examination, the Veteran reported that he fell backwards lifting his toolbox during service. He related back pain which radiated down his right thigh that has worsened since the accident. He reported that he did not receive evaluation for his back disability at that time, and he first underwent a magnetic resonance imaging (MRI) in 2009. He stated that he received injections which temporarily helped alleviate his back disability. The consulting provider diagnosed a lumbsacral sprain and opined that his back disability was less likely than not proximately due to or the result of his service-connected hernia. The examiner noted that the STRs are silent for a back injury, radiculopathy, or a toolbox injury. The STRs document an inguinal hernia related to heavy squatting and deadlifting. The examiner acknowledged the Veteran's report of a 2009 MRI and noted the MRI is not of record. The examiner did not address whether the Veteran's service-connected hernia aggravated his back disability. Accordingly, development for a fully adequate medical opinion in this matter was necessary. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). During a September 2018 VA (back) examination, the Veteran reported injuring his back picking up a toolbox while deployed. He conveyed that his back has hurt ever since, and he receives epidurals for the pain. The provider diagnosed mild degenerative disc disease (DDD) of the lower lumbar spine, pars 5 defect, and radiculopathy of the right lower extremity. The examiner opined that one episode of a lifting injury would not be severe enough to cause DDD. The DDD of the lumbar spine is most likely caused by natural causes such as the aging process. The examiner did not address the Veteran's July 2018 DRO testimony describing continuity of symptomatology regarding his back disability. Notably, DDD is a chronic disease, for which service connection may be established by showing continuity of symptomatology. Accordingly, development for a fully adequate medical opinion in this matter is necessary. See id. 2. Entitlement to service connection for diverticulitis, to include as secondary to IBS, is remanded. The Veteran's representative contends that his diverticulitis is secondary to his service-connected IBS. An April 2016 VA treatment record notes the absence of an elevated white blood cell count and a recent normal colonoscopy showing no diverticula. A subsequent April 2016 VA treatment record interpreted a computer tomography (CT) scan of the Veteran's abdominal region showed mild diffuse large bowel wall thickening primarily involving the sigmoid colon and most likely representing diverticulitis. The interpreting nurse practitioner noted potential diagnoses of possible diverticulitis, possible inflammatory bowel disease, and possible infectious colitis. A May 2016 VA treatment record notes that the Veteran presented to the VA emergency room (ER) for ongoing right hypogastric pain. He reported that he did not complete the entire course of medications for diverticulitis; and he did not undergo a recent a procedure. The doctor noted that the clinical staff were unable to fully view the recent imaging but would treat for the Veteran for diverticulitis. On September 2018 VA (Gulf War) and (intestinal conditions) examinations, the provider indicated 2012 intestinal diagnoses of IBS and diverticulitis. The examiner noted the Veteran's reports of diarrhea and abdominal distension. She concluded that there were no additional signs or symptoms of any undiagnosed illnesses. Upon a January 2019 VA addendum (gulf war) examination, the nurse practitioner, who conducted the September 2018 examination, requested that the diagnosis of diverticulitis be removed from the Veteran's records. This nurse practitioner opined that there is no supporting documentation that Veteran has had diverticulitis as the 2012 colonoscopy was normal and there is no supporting documentation to indicate an occurrence of diverticulitis since that time. She concluded, that as no basis exists for a diagnosis of diverticulitis in the record, diverticulitis cannot be related to Gulf War Syndrome. The VA opinions of record do not establish a diagnosis of diverticulitis. The September 2018 and January 2019 VA consulting providers' opinions found that there is no supporting documentation that the Veteran has had diverticulitis since the 2012 colonoscopy which was interpreted to show a normal colon. The providers' opinions did not address the April 2016 VA treatment record which reflects that a nurse practitioner interpreted a CT scan to find possible diverticulitis. Accordingly, development for a fully adequate medical advisory opinion in this matter is necessary. Barr, 21 Vet. App. 303. The matters are REMANDED for the following actions: Arrange for the Veteran's claims file to be forwarded to an appropriate clinician(s) (in orthopedics and gastroenterology) for review and a medical advisory opinion regarding the likely etiology of his claimed diverticulitis and back disability. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The examiner should provide opinions that respond to the following: (a.) Identify (by diagnosis) each back and gastrointestinal entity shown during the pendency of this claim (separate from the service-connected IBS). If diverticulitis is not diagnosed, reconcile that finding with the notations in the record suggesting otherwise. [An April 2016 VA treatment record shows a diagnosis of possible diverticulitis based on interpretation of a CT scan.] If a lumbsacral sprain, mild DDD of the lower lumbar spine, pars 5 defect, and radiculopathy of the right lower extremity are not diagnosed, reconcile that/those findings with the notions in the record suggesting otherwise. [October 2014 and September 2018 VA examinations diagnosed the above-mentioned conditions.] (b.) Identify the likely etiology for each gastrointestinal entity separate from his service-connected IBS and back entity diagnosed. Specifically, is it at least as likely as not (a 50% or better probability) that it had its onset/was incurred during the Veteran's active service? (c.) If a gastrointestinal entity separate from his service-connected IBS is diagnosed, is it at least as likely as not that the diagnosed disability was proximately caused by or aggravated beyond its natural progression by the Veteran's service-connected IBS? (d.) If a back disability is diagnosed, is it at least as likely as not that the diagnosed disability was proximately caused by or aggravated beyond its natural progression by the Veteran's service-connected status post left inguinal hernia repair? (e.) If evidence received in response to (c) and (d), above, suggests that his diagnosed back entity and/or gastrointestinal entity is found to not have been caused, but to have been aggravated, by a service-connected disability (specifically, IBS for the gastrointestinal disability and status post left inguinal hernia repair for the back disability), identify the baseline severity of such disability prior to the aggravation and the level of severity of the disability following aggravation. All opinions must include rationale that cites to supporting factual data and/or medical literature, as deemed appropriate. B. J. KOMINS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Lederman 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.