Citation Nr: 21073075
Decision Date: 12/07/21	Archive Date: 12/07/21

DOCKET NO. 16-60 055
DATE: December 7, 2021

REMANDED

Entitlement to a disability rating in excess of 20 percent for myofascial lumbar syndrome status post right sacroiliac fusion and iliac autograft (excluding periods in which a temporary total rating under 38 C.F.R. § 4.30 was in effect) is remanded.

REASONS FOR REMAND

The Veteran had active service from December 2002 to December 2006.

This matter comes before the Board of Veterans' Appeals (Board) from a rating decision issued in August 2013.  This matter was previously before the Board in December 2018.

Entitlement to a disability rating in excess of 20 percent for myofascial lumbar syndrome post right sacroiliac fusion and iliac autograft (excluding periods in which a temporary total rating under 38 C.F.R. § 4.30 was in effect)

An addendum medical opinion is necessary in order for the Board to provide an adequate adjudication of this appeal.  The Veteran's two most recent VA examinations were conducted in May 2018 and November 2020.  At the May 2018 examination, the examiner reported ranges of motion as to all directions measured for the Veteran's lumbar spine.  Some of the reported ranges of motion were values that were within normal limits, particularly the right and left lateral flexion.  However, the examiner also reported that the Veteran's spine was unfavorably ankylosed throughout the entire thoracolumbar spine.  It is unclear how the Veteran's thoracolumbar spine could be both ankylosed throughout and have such an extensive range of motion.  The ankylosis was not noted on the report of the November 2020 examination.  Consequently, the Board requires a medical explanation as to whether this indicates that the ankylosis was an inaccurate report or had resolved between the examinations.  Similarly, the report of the May 2018 examination indicates that the Veteran had intervertebral disc syndrome (IVDS), but IVDS was not noted on the report of the November 2020 examination.  Therefore, the Board requires a medical explanation as to whether the reported IVDS was an inaccurate report or resolved between the examinations.

Accordingly, this matter is REMANDED for the following actions:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's service-connected lumbar spine disorder.  The clinician should review the claims file, including in particular, the reports of the May 2018 and November 2020 examinations.  In the event that the questions annotated below cannot be answered without an examination, the Veteran should be scheduled for an appropriate examination.  Specifically, the clinician should:

(a.) Discuss the possibility of the co-occurrence of both the significant range of motion reported for the Veteran's lumbar spine and the unfavorable ankylosis throughout the entire thoracolumbar spine reported on the May 2018 VA examination.

(b.) Opine, to the extent possible, whether the ankylosis and IVDS documented on the report of the May 2018 examination were accurate reports of the Veteran's symptomatology or if the absence of these symptoms in the report of the November 2020 examination report indicates that these aspects of the Veteran's condition resolved.

2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal.  If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond.  If necessary, return the case to the Board for further appellate review. 

 

THERESA M. CATINO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Steven H. Johnston, 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.