Citation Nr: 21073264
Decision Date: 12/08/21	Archive Date: 12/08/21

DOCKET NO. 17-27 153
DATE: December 8, 2021

REMANDED

Entitlement to service connection for a thoracolumbar spine disability, to include low back pain, is remanded.

Entitlement to service connection for a cervical spine disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from August 1979 to August 1983. 

The Board remanded the claim in February 2019 for further development. 

1. Thoracolumbar spine disability, to include low back pain  

The Veteran has a current diagnosis of degenerative arthritis of the lumbar spine as evidenced by the October 2019 VA examination. The examiner's opinion omits from the "submitted medical evidence" paragraph any discussion of the VA October 2017 lumbar spine MRI, which was referenced in VA neurosurgery notes. It further omits reference to the fact that the Veteran was being seen by VA neurosurgery for spine issues to include low back pain. Based on this, it is unclear if the October 2019 VA examiner based his opinion on an accurate medical history. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). An adequate examination is needed.

2. Cervical spine disability

The Veteran has a cervical spine disability as indicated by a VA March 2018 CT scan. In a June 2020 letter, he contends that his current cervical spine disability is directly related to service and the thoracolumbar spine disability is secondary to the cervical spine disability. The Veteran further has degenerative disc disease of the thoracic spine as seen by a February 2019 VA MRI. A VA examination is needed. 

The matters are REMANDED for the following action:

1. Obtain updated VA treatment records.

2. Thereafter, schedule the Veteran for a VA examination for his thoracolumbar and cervical spine disabilities. The examiner must review the claims file.  The examiner should consider diagnoses from ongoing treatment with neurosurgery at VA, to include the October 2017 MRI, March 2018 CT scan, and February 2019 MRI.

The examiner is asked to provide a response to the following:

a)	Is the thoracolumbar spine disability at least as likely as not related to service, including slipping from the flight deck, jumping onto the catwalk, and being hit by tow tractors in service.

b)	Is the cervical spine disability at least as likely as not related to service, including carrying heavy chains around in service? 

In providing the requested opinions, consider the Veteran's description of his in-service symptoms as well as his post-service symptoms.  If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted.  Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible?

c)	Is it at least as likely as not that the thoracolumbar spine disability (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service?

d)	Is it at least as likely as not that the cervical spine disability (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service?

e)	Is the thoracolumbar spine disability at least as likely as not proximately due to the cervical spine disability?

f)	Is the thoracolumbar spine disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the cervical spine disability?

 

Provide a detailed rationale to support the opinions rendered.  

 

 

Nathaniel J. Doan

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	AD

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.