Citation Nr: 21076636
Decision Date: 12/27/21	Archive Date: 12/27/21

DOCKET NO. 17-35 957
DATE: December 27, 2021

REMANDED

Entitlement to service connection for a thoracolumbar spine condition, to include as secondary to service-connected bilateral knee disabilities, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1983 to May 1993, with additional periods of active duty for training and inactive duty training.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).  

This matter was previously before the Board in February 2019 and September 2021, when it was remanded for further development.  

In this case, the Board requested opinions regarding whether the Veteran's low back condition is related on a secondary basis to his service-connected bilateral knee disabilities.  Opinions were obtained in April 2020 and October 2021.  However, both opinions state as a rationale that there is no evidence to support causation or aggravation of the Veteran's low back condition by his service-connected bilateral knee disabilities.  The Board finds these opinions inadequate as the rationales do not consider facts and evidence pertaining specifically to the Veteran and merely provide a conclusory statement that no evidence in the record supports a nexus on a secondary basis.  In addition, the opinions did not provide any supporting facts, analysis, or evidence, nor explain how or why the conclusions were reached.  Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim).  In addition, the examiner did not address the Veteran's statements in the October 2021 spine examination report regarding his low back pain and aches radiating "down his right leg with numbness down to his knee." 

As such, the Board finds that an addendum opinion (and examination, if found necessary) should be provided on remand to address the deficiencies noted above.  

The matters are REMANDED for the following action:

Obtain an addendum medical opinion from an appropriate examiner.  An examination should be scheduled for the Veteran if found necessary by the examiner.  The claims file should be made available to and reviewed by the examiner, and the examiner should specifically note that such review was performed.  

Following consideration of the evidence of record (both lay and medical), including the Veteran's reported symptoms regarding his low back pain radiating down his right leg with numbness in the knee, the examiner is asked to address the following:

(a) For each low back condition diagnosed, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it was caused by the Veteran's service-connected bilateral knee disabilities.  

(b) For each low back condition diagnosed, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it was aggravated beyond the normal course of the condition by the Veteran's service-connected bilateral knee disabilities.  

The examiner must address both causation and aggravation for the opinions to be deemed adequate.  The examiner should be aware that Ward v. Wilkie, 31 Vet. App. 233 (2019) held that a "permanent worsening" of a nonservice-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability).

The examiner should provide a detailed and medically-supported rationale for all opinions given.

 

 

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Ariasaif, Mary

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.