Citation Nr: 21010620 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-48 579 DATE: February 25, 2021 REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for radiculopathy of bilateral lower extremities is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1987 to July 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions rendered in March 2016 and August 2016. In an October 2019 decision, the Board denied these claims. The Veteran appealed the Board’s decision to the U.S. Court of Appeals for Veterans Claims (Court). In October 2020, the Court issued an Order granting a Joint Motion for Remand (Joint Motion), which vacated the Board’s October 2019 denial of the claims. 1. Entitlement to service connection for a lumbar spine disorder is remanded. The Veteran contends he has a present lumbar spine disorder caused by injuries during active service and has radiculopathy of the bilateral lower extremities as well as an acquired psychiatric disorder secondary to that lumbar spine disorder. In the October 2020 Joint Motion, the parties found that the Board erred when it did not ensure that VA satisfied the duty to assist and did not provide an adequate statement of reasons or bases with respect to the claim by relying on an inadequate VA examination of the lumbar spine. It was noted that the February 2016 VA examiner failed to properly consider findings in a July 11, 1989 service treatment record that reflected a recent weightlifting injury as well as a history of a prior muscle injury just three months before. Pursuant to the October 2020 Joint Motion and based on the cumulative evidence of record, the Board finds that a VA medical opinion clarifying the etiology of the Veteran’s claimed lumbar spine disorder is necessary to effectively adjudicate the service connection claim on appeal. In addition, updated copies of all pertinent VA treatment records should also be obtained and properly associated with the record. 38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for radiculopathy of bilateral lower extremities is remanded. 3. Entitlement to service connection for an acquired psychiatric disorder is remanded. As a decision on the remanded service connection issue for a lumbar spine disorder could significantly impact a decision on these matters, the issues are inextricably intertwined and remand of the service connection claims for bilateral lower extremity and psychiatric disorders are required. The matters are REMANDED for the following actions: 1. Obtain updated treatment records pertaining to the Veteran’s claimed lumbar spine, bilateral lower extremity, and acquired psychiatric disorders from Dallas VAMC for the time period from June 2016 to the present and associate them with the record. 2. Thereafter, obtain a VA medical opinion to clarify the etiology of the Veteran’s claimed lumbar spine disorder from an appropriate examiner, preferably an orthopedic specialist. If an opinion cannot be provided without an examination, one should be provided. The electronic claims file must be made available to the examiner, and the examiner must specify in the report that the file has been reviewed. The examiner should extensively review the evidence of record and furnish an opinion with a well-supported rationale for the following inquiry: For each diagnosed lumbar spine disorder of record, to include lumbosacral strain, s/p laminectomy and discectomy L5/S1, mechanical back pain syndrome, and intervertebral disc syndrome, the examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s lumbar spine disorder began during or was causally related to events during active service, including documented in-service lumbar spine complaints and treatment (including the July 11, 1989 service treatment record that reflected a recent weightlifting injury as well as a history of a prior muscle injury three months before). In doing so, the examiner should discuss and reconcile the findings contained in the Veteran’s service treatment records; post-service VA and private treatment records; the Veteran’s lay statements concerning in-service symptomatology and post-service spine surgery in 2004 as well as the June 2019 lay assertions from a fellow serviceman; the October 2017 DBQ and medical opinion from the Veteran’s private treatment provider, R. S., D. C.; and the February 2016 VA examination report and medical opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on his claims. 38 C.F.R. § 3.655 (2020). 3. After completing the above actions and any other necessary development, the claims on appeal must be readjudicated, taking into consideration all relevant evidence associated with the record since the January 2018 SSOC. If any benefit on appeal remains denied, a SSOC must be provided to the Veteran and his attorney. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. D. Deane, 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.