Citation Nr: 21007514 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-38 456 DATE: February 9, 2021 REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to a lumbar spine disorder, is remanded. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to a lumbar spine disorder, is remanded. REASONS FOR REMAND The Veteran served honorably in the Navy from July 1987 to January 1991. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. In October 2020, the Veteran provided testimony via video conferencing hearing before the undersigned Veterans Law Judge. 1. Entitlement to service connection for a lumbar spine disorder is remanded. Remand is required for an adequate VA examination an opinion for lumbar spine disorder. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran received a back examination in September 2016. The examiner opined the back disorder was less likely than not incurred in or caused by service, noting the Veteran had a self-limiting low back strain during active duty which was treated conservatively. The examiner stated that his low back symptoms were well documented in service treatment records (STRs) pointing to a February 1990 STR noting no further back pain symptoms. Further, the examiner explained the Veteran has not sought care for chronic low back condition in well over two decades since active duty. The examiner concluded the Veteran has age related DJD in lumbar spine consistent with five decades of life. The examiner determined his current back symptoms are related to wear and tear issues, not to a resolved back strain twenty-five years ago. In the medical history section of the examination report the examiner acknowledged the STRs documented the Veteran sustained a lumbar sprain during active duty in December 1987 and in January 1970 the Veteran sustained a second back sprain while moving boxes and was again diagnosed with low back strain/mechanical low back. The examiner also indicated the Veteran has never had physical therapy for his low back. First, the examiner failed to address the Veteran’s contention of back pain that has continued since service. Notably, in an August 2012 VA treatment record the Veteran reported recurrent low back pain - lumbar area, after initial injury with heavy lifting years ago, while on active duty. Also, during the October 2020 Board hearing, the Veteran indicated he self-treated his back pain after service; however, his symptoms progressed requiring him to seek treatment. Accordingly, remand is required to address the Veteran’s contentions. Next, the examiner’s rationale was based on an inaccurate factual premise and/or did not address all the relevant information. An October 1987 STR documents the Veteran initially injured his back while lifting desks. Further, the examiner noted the Veteran sustained a second injury in January 1970; however, the Veteran was not in service in January 1970. Lastly, the examiner noted the Veteran has not sought treatment since 1990 and never had physical therapy. However, VA treatment records document the Veteran complained and received treatment for low back pain. Thus, remand is required. 2. Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to a lumbar spine disorder is remanded. 3. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to a lumbar spine disorder is remanded. Remand is required because entitlement to service connection for bilateral lower extremity radiculopathy is inextricably intertwined with the pending claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The Veteran alleges that his bilateral lower extremity radiculopathy is a result of a lumbar spine disorder. See October 2020 Board hearing. The matters are REMANDED for the following action: Obtain an addendum opinion to determine the etiology of his back disorder. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, one must be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the back had onset in, or is otherwise related to, active military service. The examiner must address the following: 1) the Veteran’s assertions of an in-service back symptoms that have continued since service; 2) the October 2020 Board hearing testimony; 3) the September 2016 VA examination; 3) the VA treatment records documenting complaint and treatment for low back pain, including physical therapy; and 4) any relevant service treatment records, including the October 1987, December 1987, April 1988, May 1988, and January 1990 records. For purposes of providing this opinion only, the examiner must presume that the Veteran had intermittent back pain since service. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Braxton, 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.