Citation Nr: 21074866 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 18-49 925 DATE: December 16, 2021 REMANDED Entitlement to service connection for a low back disorder, including decompression and laminectomy of the lumbar spine, is remanded. Entitlement to service connection for painful scar as secondary to a low back disorder, including decompression and laminectomy of the lumbar spine, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1971 to August 1974. This matter comes before the Board of Veterans' Appeals (Board) from an April 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in June 2020. A transcript of that hearing has been added to the Veteran's file. 1. Entitlement to service connection for a low back disorder is remanded. Although the Board regrets further delay, remand is necessary to obtain a VA medical opinion. The Veteran and his wife, who have been married since he was in service, have recounted the pain that the Veteran experienced due to his back in service while working as an engineer building bridges, buildings, and carrying heavy equipment. The Veteran testified that he sought private treatment for his back, but the records are no longer available. Additionally, the Veteran's wife submitted copies of her diary from her husband's time in service, which recounts his complaints of back pain. He additionally testified that he did not seek treatment through the Army for fear of being sent to Vietnam. The Veteran's service treatment records are silent for any complaints, treatment, or diagnosis for a back condition. The initial post-service VA treatment record showing complaints of back pain notes the Veteran's report that he injured back about 15 years ago lifting a load of logs, so in approximately 1985. See VA treatment note, dated March 9, 2000. However, the Board has determined that this has raised the possibility of substantiating the Veteran's claim, and as such, the Board finds that the low threshold to warrant a VA examination has been met. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Further, on remand the Veteran's complete medical records from his service in the Reserves, as well as his treatment records from Dr. Capapano, should be obtained. 2. Entitlement to service connection for painful scar as secondary to decompression and laminectomy of the lumbar spine is remanded. Finally, because a decision on the remanded issue of service connection for the back could significantly impact a decision on the issue of service connection for a back scar, the issues are inextricably intertwined. A remand of the claims is required. The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran's complete medical treatment records from his service in the Army Reserves. 2. Make arrangements to obtain the Veteran's complete medical treatment records from Dr. Capapano. 3. Make arrangements to obtain the Veteran's updated VA treatment records. 4. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current back condition onset during service or is otherwise related to an in-service injury, event, or disease, to include as due to basic training as well as his work as an engineer building bridges, buildings, and carrying heavy equipment. In offering the opinion, the examiner should consider the diary of the Veteran's wife showing that the Veteran was experiencing back symptoms in 1982. The examiner should also 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? (Continued on the next page) The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hofmeister 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.