Citation Nr: 21077595 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 15-33 151 DATE: December 30, 2021 REMANDED Entitlement to service connection for a recurrent lumbar spine disability, to include degenerative disc disease, laminectomy residuals, discectomy residuals, and fusion residuals, is remanded. Entitlement to service connection for a right lower extremity disability, to include radiculopathy, is remanded. Entitlement to service connection for left lower extremity disability, to include radiculopathy, is remanded. REASONS FOR REMAND The Veteran had active service from August 1980 to August 1984. 1. Entitlement to service connection for a recurrent lumbar spine disability, to include degenerative disc disease, laminectomy residuals, discectomy residuals, and fusion residuals, is remanded. The Veteran contends that service connection for a recurrent lumbar spine disability is warranted as the claimed disability was manifested during active service. The report of the April 1980 physical examination for service entrance states that no lumbar spine disability was found. The service treatment records reflect that the Veteran was treated for a lumbar spine injury. Clinical documentation dated in January 1983 states that the Veteran complained of back pain after lifting a piece of equipment. He was diagnosed with low back strain. The report of a July 2012 Department of Veterans Affairs (VA) spine examination states that the Veteran was diagnosed with lumbar spine degenerative disc disease, laminectomy residuals, discectomy residuals, and fusion residuals. The examiner noted that the Veteran had a history of a 1983 in service low back lifting injury and a post service 1994 fall in which he struck his back against a steel rod and sustained a herniated disc. She opined that: "the claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in service injury, event, or illness;" "the Veteran recovered for duty in the Reserves;" "so in this provider's opinion, the 1983 incident did not aggravate the condition beyond its course;" and "the event which aggravated the condition beyond its natural course was the post service 1994 incident." The VA nurse practitioner did not provide any objective evidence of a pre existing recurrent lumbar spine or any rationale for her conclusion that the diagnosed lumbar spine disability existed prior to service entrance. Further, the Board of Veterans' Appeals (Board) observes that the record does not establish, and the Veteran specifically denies, any duty with a reserve military organization. In light of the concurrent findings that the diagnosed lumbar spine disability was both aggravated by an in service injury and was "aggravated" instead by a post service fall, the Board is unable to discern whether the examiner found that a pre existing lumbar spine disability was aggravated by the documented in service lifting injury. Given the cited deficiencies, the Board finds that the examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA spine examination is needed. Clinical documentation dated after March 2013 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for a recurrent right lower extremity disability to include radiculopathy and a left lower extremity disability to include radiculopathy is remanded. The issues of service connection for a recurrent right lower extremity disability and a recurrent left lower extremity disability to include radiculopathy are inextricably intertwined with the issue being remanded and must also be remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who treated him for any lumbar spine, right lower extremity, and left lower extremity disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain all relevant VA clinical documentation not already of record, including that pertaining to treatment after March 2013. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the nature and etiology of any identified recurrent lumbar spine disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent lumbar spine disabilities found. (b) Opine as to whether it is at least as likely as not (50 percent probability or greater) that any identified lumbar spine disability had its onset during active service or is related to any incident of service, including the documented in service January 1983 lumbar spine lifting injury and diagnosed low back strain. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Casula 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.