Citation Nr: 21007580 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 16-41 110 DATE: February 10, 2021 REMANDED Entitlement to service connection for thoracolumbar spondylosis and degenerative disc disease without radiculopathy and/or a cervical spine disability is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1998 to July 2002. In December 2020, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. At the hearing, the Veteran submitted statements from two of his acquaintances and a physician in support of his claim which are considered herein. Furthermore, the record was held open for 30 days for the additional submission of evidence; however, no additional evidence was received. Entitlement to service connection for thoracolumbar spondylosis and degenerative disc disease without radiculopathy and/or a cervical spine disability is remanded. The Veteran’s claim has been developed and adjudicated as one for service connection for thoracolumbar spondylosis and degenerative disc disease without radiculopathy. See June 2013 rating decision; June 2016 Statement of the Case. However, it is noted that in his January 2012 claim for compensation benefits, the Veteran claimed service connection for both a back injury and a neck injury, and reported that he suffered a back and neck injury while installing an antenna element during a field training exercise during his active duty military service in Fort Hood, Texas. See VA Form 21-526. The Veteran provided more clarity to his benefits claim during the December 2020 hearing. At the hearing, he explained an injury he suffered to his back as well as his neck during his military service. Specifically, he was attaching or installing an antenna element on the back of a tank, which was a part of their communication system, when he fell off the tank from the top. When he fell, he hit his back. He testified that he was taken to a base hospital for treatment and was put on profile after this incident for roughly three months, which exempted him from all physical fitness activities. He also testified that he felt his injury had progressed since that time in both his back and neck. In light of the Veteran’s contentions and how his claim was filed, the Board has recharacterized the issue on appeal, as indicated above, to include consideration of the cervical spine. A VA examination was performed in June 2013 which evaluated the Veteran’s lumbar spine. The examiner found it was less likely than not that the Veteran’s currently diagnosed thoracolumbar spondylosis and degenerative disc disease was related to any in-service injury, largely relying on a lack of evidence documenting his in-service injury. See June 2013 VA examination. Here, however, unfortunately, the Veteran’s complete service treatment records are unavailable for review. See VA Memo. Therefore, his in-service injury is unable to be corroborated based on his service treatment records alone. Since the time of the last VA examination, new evidence has been added to the claims file which is important to consider in determining the nature and etiology of the Veteran’s disabilities. For example, the record now includes the Veteran’s lay hearing testimony as well as a statement from D.H., which describes the Veteran’s in-service injury to his neck and back as well as a medical statement from Dr. K.M. who has treated the Veteran’s cervical injury he “sustained while serving in the military”. See Statements received in January 2021. Additionally, while the June 2013 examiner examined and provided an opinion regarding the Veteran’s thoracolumbar spondylosis, the examination did not address whether the Veteran had a cervical spine disability stemming from the same in-service injury. Therefore, in consideration of the Veteran’s December 2020 hearing testimony; the lay statements from others, which he submitted in support of his claim; the medical statement from Dr. K.M.; and VA’s heightened duty to assist, as a result of the Veteran’s complete service treatment records being unavailable, the Board finds a new VA examination that evaluates the nature and etiology of any cervical spine disability, as well as a back disability, is required. The matter is REMANDED for the following action: Schedule the Veteran for a VA examination for his lumbar spine and cervical spine disabilities. The examiner must review the claims file (including this remand). If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following for each disability: (Continued on the next page)   Are the disabilities to the Veteran’s neck and back at least as likely as not related to service, including as a result of the in-service accident? The examiner is asked to consider the lay statements from the Veteran and his acquaintances, as well as the medical statement from Dr. K.M., which discuss the Veteran’s in-service injury. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Churchwell, 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.