Citation Nr: A21020065 Decision Date: 12/16/21 Archive Date: 12/15/21 DOCKET NO. 200518-84142 DATE: December 16, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for lumbar spine disc herniation with mild central canal stenosis and neural stenosis of the L4-L5 and L5-S1 and spondylosis is remanded. Entitlement to an initial rating in excess of 10 percent prior to January 7, 2020 and in excess of 20 percent thereafter for central disc herniation with mild central canal stenosis at C5-C6 is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1999 to March 2004. He received the combat action badge for his service. This case comes before the Board of Veterans' Appeals (Board) from a May 2020 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) decided pursuant to the Appeals Modernization Act (AMA). In May 2020, the Veteran submitted a VA Form 10182 (Decision Review Request: Board Appeal) and elected Direct Review. Accordingly, the Board may only consider the evidence of record at the time of the AOJ decision on appeal. Evidence was added to the claims file after the submission of the VA Form 10182 which the Board is prohibited from reviewing. As the claims of increased ratings for the Veteran's neck and back disabilities are being remanded for further development, this additional evidence will be considered by the RO in the adjudication of those claims. 1. Entitlement to an initial rating in excess of 10 percent for lumbar spine disc herniation with mild central canal stenosis and neural stenosis of the L4-L5 and L5-S1 and spondylosis is remanded. 2. Entitlement to an initial rating in excess of 10 percent prior to January 7, 2020 and in excess of 20 percent thereafter for central disc herniation with mild central canal stenosis at C5-C6 is remanded. The Veteran has consistently contended since filing his initial claim for VA compensation for thoracolumbar and cervical spine disabilities that he experiences back and neck pain with muscle spasms. In an October 2015 Statement in Support of Claim, the Veteran indicated that he experiences severe pain and spasms daily when he is mobile but requires an Emergency Room visit (ER) when he becomes immobile. VA treatment records including those dated July 2015, December 2015, and March 2016 indicated a diagnosis of spinal muscle spasms that required prescription muscle relaxers such as Flexeril. A VA Back (Thoracolumbar spine) examination and VA Neck (Cervical spine) examination dated January 2018 are silent for any indication of muscle spasms. The examiner who performed a VA Back (Thoracolumbar spine) examination and a VA Neck (Cervical spine) examination in January 2020, indicated that the Veteran's self-reported symptoms included muscle spasms; however, the reports do not indicate if there is abnormal gate or abnormal contour. The Board finds that both the January 2018 and the January 2020 VA examinations are inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: Obtain an opinion from the January 2020 examiner or another qualified clinician if the January 2020 examiner is not available. The examiner is instructed to review all pertinent records associated with the claims file. Does the Veteran have muscle spasms severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis during any portion of the period from December 22, 2014 to August 20, 2020? Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Alexander 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.