Citation Nr: 21074852
Decision Date: 12/16/21	Archive Date: 12/16/21

DOCKET NO. 19-13 812
DATE: December 16, 2021

REMANDED

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

REASONS FOR REMAND

The Veteran served on active duty from June 1965 to June 1968.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from the August and September 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). 

This case was last remanded in May 2021 to obtain an adequate VA medical opinion as to the etiology of the Veteran's current back disability.  The Board requested that the examiner consider the Veteran's lay reports of continuing back pain since service when providing the opinion.  An examiner provided another opinion in June 2021 as well as an addendum in the following month.  The VA examiner acknowledged that the Veteran sustained a contusion of the sacrum during service in 1968 but opined that the Veteran's current osteopenia is less likely as not related to that incident.  

However, in providing rationale, the examiner did not address the Veteran's competent lay reports of continued back pain since service, as specifically requested in the prior remand.  Moreover, the examiner recognized prior x-ray evidence of a compression fracture in the thoracic region of the spine, which the Board observes was first noted in approximately 2011.  This finding of a compression fracture raises the question of whether it represents a continuation of the low back injury in service.  

For these reasons, another etiology opinion is requested.    

The matter is REMANDED for the following action:

1. Ensure all outstanding VA treatment records are associated with the claims file. 

2. Thereafter, obtain an addendum as to the likely etiology of the current lumbar spine disability.  The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. 

The examiner is asked to respond to the following:

(a)	Review the record, specifically to include the June 2021 VA opinion (and July 2021 addendum) finding the Veteran's osteopenia less likely as not related to service, and then: 

(b)	Clarify whether the June 2021 opinion still stands.  If so, reconcile it with the Veteran's reports of having had back pain since the in-service low back injury, which have been deemed competent by the Board. 

(c)	Review the treatment records beginning in and around 2011 showing a history of a compression fracture in the T-spine and then provide an opinion as to whether the compression fracture is at least as likely as not related to the in-service low back injury (i.e., is it a continuation of the in-service injury?).  Please explain your reasoning in full.

 3.  After ensuring that the above-requested opinions are adequately answered, then readjudicate the remanded claim.

 

 

S. B. MAYS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Moldawer, 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.