Citation Nr: 21012198 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 13-03 245A DATE: March 3, 2021 ORDER Entitlement to an initial disability rating in excess of 20 percent for lumbar anterolisthesis with disc desiccation and disc bulge with left paracentral extrusion (lumbar spine disability) is denied. Prior to November 25, 2016, entitlement to an initial 10 percent disability rating, but no higher, for radiculopathy, left lower extremity is granted. From November 25, 2016, entitlement to a disability rating of 20 percent, but no higher, for radiculopathy, left lower extremity is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s lumbar spine disability has been manifested by limitation in forward flexion of the thoracolumbar spine to no less than 45 degrees, including additional limitation after repetitive use or flare-ups; limitation of forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the lumbar spine were not approximated. 2. Prior to November 25, 2016, the Veteran’s left lower extremity radiculopathy was manifested by mild incomplete paralysis of the sciatic nerve; moderate incomplete paralysis of the sciatic nerve was not approximated. 3. From November 25, 2016, the Veteran’s left lower extremity radiculopathy was manifested by moderate incomplete paralysis of the sciatic nerve; moderately severe incomplete paralysis of the sciatic nerve was not approximated. 4. The Veteran’s service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for initial rating in excess of 20 percent for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5299-5243. 2. Prior to November 25, 2016, the criteria for entitlement to an initial disability rating of 10 percent, but no higher, for radiculopathy, left lower extremity were met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.124, 4.124a, DC 8520. 3. From November 25, 2016, a disability rating of 20 percent, but no higher, for radiculopathy, left lower extremity have been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.124, 4.124a, DC 8520. 4. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1974 to July 1977. In December 2016, the Veteran testified before the undersigned at a Travel Board hearing. A transcript of the hearing is associated with the record. In August 2017, the Veteran’s claim was by the Board for additional development. Review of the completed development reveals that, at the very least, substantial compliance with the remand directives was obtained. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The issue of entitlement to service connection for an acquired psychiatric disorder was remanded by the Board in August 2017. The Agency of Original Jurisdiction (AOJ) granted service connection for Unspecified Depressive Disorder in a February 2020 rating decision. That issue, having been granted in full, is no longer for appellate review. Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Increased Ratings, Generally Disability evaluations (ratings) are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to an initial rating in excess of 20 percent for the Veteran’s lumbar spine disability The Veteran has contended that a higher disability rating is warranted for his lumbar spine disability. The Veteran’s condition is rated under DC 5299-5243. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that an unlisted musculoskeletal disorder (DC 5299) is rated under the criteria for intervertebral disc syndrome (DC 5243). See 38 C.F.R. § 4.20. The Veteran’s condition can either be evaluated according to the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or according to the Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episodes Formula). 38 C.F.R. § 4.71a, DC 5235-5243. Regulatory changes in February 2021 continue to support the application of the codes relating to IVDS given the nature of the Veteran’s diagnosis. Under the General Formula, a 10 percent rating will be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of the height. A 20 percent rating will be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, with a combined range of motion not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait; or, abnormal spinal contour, such as scoliosis, reversed lordosis or abnormal kyphosis. A 40 percent evaluation is warranted under the General Formula when there is forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted where there is unfavorable ankylosis of the entire spine (meaning when considering the adjacent cervical segment as well). See 38 C.F.R. § 4.71a, DC 5242, General Formula. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See id., Note (5). The General Formula applies for rating purposes with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. When rating according to the General Formula, any associated objective neurologic abnormalities are rated separately under their respective diagnostic codes. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Veteran’s lumbar spine disability can also be rated using the Incapacitating Episodes Formula. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. This formula allows for a rating of 20 percent if there have been incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months; a 40 percent evaluation was assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past twelve months; and a 60 percent evaluation was assigned for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Incapacitating Episodes Formula. For the purposes of this formula, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). Unfortunately, the Board finds that throughout the appeal period that the criteria for a rating in excess of 20 percent is not warranted. The Veteran's lumbar spine disability was evaluated during VA examinations in May 2010 and January 2018. The Veteran also underwent a private medical evaluation in February 2017. The Board finds that these examinations and the other medical evidence of record demonstrates that the Veteran's lumbar spine condition causes stiffness, weakness, an abnormal gait and reduced forward flexion of the lumbar spine; however, the Veteran’s condition has not been shown to more nearly approximate forward flexion to 30 degrees or less throughout the appeal period, which would warrant a higher 40 percent rating. (As will be discussed further below, the Board notes that under the General Rating Formula any associated objective neurologic abnormalities, including radiculopathy, should be rated separately under an appropriate diagnostic code.) Unfortunately, a rating in excess of 20 percent under the General Rating Formula, however, is not warranted because the competent, credible evidence of record shows thoracolumbar range of flexion beyond 30 degrees throughout the period on appeal. Neither the May 2010 VA examination or January 2018 VA examination reported limitation of lumbar flexion to 30 degrees or less. Rather, each examination reported lumbar flexion beyond 30 degrees. The May 2010 examination reported that the Veteran’s condition results in stiffness, weakness, and an abnormal gait and forward flexion of the lumbar spine to 45 degree with pain beginning at that point. No additional limitation was reported after repetitive motion or flare-ups. Further, the January 2018 examination reported lumbar flexion to beyond 60 degrees and did not report additional limitation after repetitive use or flare-ups, which were denied by the Veteran. The Board finds the findings of the 2010 and 2018 VA examiners to be of greater probative value regarding the limitation of the Veteran’s lumbar spine range of motion than the findings reported by the 2017 private examiner. The Board notes that the examiner does not specifically report findings regarding the Veteran’s range of motion of the lumbar spine. In the physical examination section of the report, the examiner does not report having tested the Veteran’s range of motion of the lumbar spine. In the question and response section, the examiner states, “the Veteran has pain in “what I think is 31 to 60 degrees and this is due to manipulation of the left ankle and straight leg raising.” The examiner reports that the pain occurs in result to manipulation of the left leg and ankle, indicating the pain being discussed may not be related to the lumbar spine. Additionally, the examiner’s use of the phrase “I think” calls into question the accuracy of the method of testing used by the private examiner. (The private examiner does not report using a goniometer). As such, the Board affords the findings of the 2017 examiner, to the extent that he indicates limitation of range of motion of the lumbar spine to 30 degrees or less, less probative weight than the findings provided by the 2010 and 2018 VA examiners that each report lumbar spine forward flexion to at least 45 degrees. Additionally, while the Veteran’s treatment records from the Ocala Community Based Outpatient Clinic (CBOC) and Gainesville VA Medical Center have reported decreased range of back flexion, the Veteran’s treatment records do not report limitation of flexion of the lumbar spine to 30 degrees or less. It is not disputed that the Veteran has pain on motion, or other factors affecting function loss of the lumbar spine, such as weakness, fatigability, etc. However, the Board finds that the evidence of record demonstrates that the Veteran’s current 20 percent rating encompasses his complaints of pain and functional loss due to the lumbar spine disability. See DeLuca, 38 C.F.R. §§ 4.40, 4.45. Further, there was no additional limitation of joint function due fatigue, or lack of endurance noted after repetitive motion. While the Veteran reported flare-ups in 2010, the examiner did not report additional limitation of range of motion at that time and the Veteran denied flare-ups during the 2018 examination. Accordingly, the Board finds that the competent, credible evidence of record does not more nearly approximate limitation of range of motion of the lumbar spine to 30 degrees or less and a disability rating in excess of 20 percent is not warranted under the General Rating Formula. 38 C.F.R. § 4.71a, DC 5242. To the extent that the Veteran reported “incapacitating” back pain in 2010 that was limiting his ability to work, the Board notes that the examiner reported that the Veteran was not suffering from incapacitating episodes related to his back disability and that the Veteran specifically denied any periods of prescribed bed rest during the prior year. Neither the Veteran, nor his medical records indicate that he has required periods of bed rest that would warrant a rating in excess of 20 percent (and a combined rating for his separately evaluated radiculopathy). Accordingly, a rating in excess of 20 is not warranted under the General Rating Formula or the Formula for Rating Intervertebral Disc Syndrome. 38 C.F.R. § 4.71a, DC 5243. For these reasons, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran’s lumbar spine disability throughout the appeal period. 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5299-5243. Entitlement to a compensable rating for radiculopathy left lower extremity prior to November 25, 2016; and in excess of 10 percent, thereafter As discussed above, under the General Formula, associated objective neurologic abnormalities are rated separately under their respective diagnostic codes. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). As such, entitlement to a compensable rating for left lower extremity radiculopathy prior to November 25, 2016, and a disability rating in excess of 20 percent, thereafter, is considered part and parcel of the Veteran’s higher initial rating claim for his lumbar spine disability. After resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran’s left lower extremity radiculopathy warrants a 10 percent rating prior to November 25, 2016, and a 20 percent rating, but no higher, thereafter. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is assignable for moderately severe incomplete paralysis. A 60 percent rating is assignable for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is assignable for complete paralysis of the sciatic nerve, in which the foot dangles and drops and there is no active movement possible of muscles below the knee, flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. The terms “mild,” “moderate,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The term “incomplete paralysis” indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Prior to November 25, 2016 Prior to November 25, 2016, the Veteran complained of left lower extremity radiculopathy symptoms. During the Veteran’s May 2010 back examination, the examiner stated that the Veteran has pain and numbness that radiates to the left lateral thigh, anterior knee, calf and dorsum of his foot. The Veteran was also reported to have weakness of the quadriceps, hamstrings, tibialis, anterior extensors of the foot and toes, and flexors of the foot. Neurological examination, however, reported normal and symmetric patellar and Achilles reflexes. The examiner opined that no objective evidence of radiculopathy was present the Veteran’s effort on motor/strength examination was reported to be intermittent. A March 2012 primary care note from the Ocala CBOC, however, provides a diagnosis of lumbar radiculopathy. A primary care note from August 2014 indicated a positive straight leg test and difficulty with toe walking. Sensation and deep tendon reflexes were reported to be present and heel walking was normal. The Board that a 10 percent rating, but no higher, should be assigned prior to November 25, 2016 based upon symptoms of “mild” left lower extremity radiculopathy. The evidence indicates a diagnosis of lumbar radiculopathy and the Board finds credible the Veteran’s reports of pain and numbness that radiates to the left lateral thigh, anterior knee, calf and dorsum of his foot. As such, the Board finds that a 10 percent rating is warranted for left lower extremity radiculopathy prior to November 25, 2016. The Board finds that a rating in excess of 10 percent, however, is not warranted prior to November 25, 2016. Under DC 8520, a 20 percent rating is only warranted for “moderate” incomplete paralysis of the sciatic nerve. While the Veteran reported recurrent symptoms of pain and numbness that radiates into the left lower extremity, the Board finds probative the report of the May 2010 examiner that the objective evidence of radiculopathy was not found to be present during the examination. Further, the August 2014 primary care physician stated that neurological testing indicated that sensation and deep tendon reflexes were present in the left lower extremity and that heel walking was normal. As such, the Board finds that the Veteran’s symptoms indicate left lower extremity radiculopathy that is no more than “mild” and that a 10 percent rating, but no higher, is warranted prior to November 25, 2016. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. From November 25, 2016 The Board finds that the evidence indicates that the Veteran’s left lower extremity radiculopathy worsened throughout the period on appeal. See Fenderson. The Board finds that from November 25, 2016, a 20 percent disability rating, but no higher, is warranted for the Veteran’s left lower extremity radiculopathy. The February 2017 and January 2018 examinations each indicate that the Veteran suffers from left lower extremity radiculopathy. The February 2017 examiner stated that the Veteran had significant difficulty walking on his heels on the left side. It was also reported that the Veteran had difficulty walking on the balls of his feet and maintaining balance. The Board finds that a 20 percent, but no higher, rating is warranted for “moderate” incomplete paralysis of the sciatic nerve. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. The Board notes the argument provided by the Veteran’s representative in March 2020 that a 40 percent rating should be assigned for “moderately severe” radiculopathy of the left lower extremity based upon the findings of the February 2017 private examiner. The weight of the competent, credible evidence of record, however, does not support a rating in excess of 20 percent for left lower extremity radiculopathy during the appeal period. To the extent that the 2017 private examiner opined that the Veteran’s condition resulted in “moderately severe” incomplete paralysis of the sciatic nerve, the Board finds probative the report of the January 2018 VA examiner that reported “mild” symptoms of left lower extremity pain and “moderate” numbness of the left lower extremity. The 2018 examiner opined that the overall symptoms of the Veteran’s left lower extremity radiculopathy was “mild.” While the 2018 examiner noted decreased sensation of the left ankle and foot/toes, neither was reported to be absent. The 2018 examiner also reported normal muscle strength of the left ankle and knee and the foot indicated active movement against some resistance (4/5). The Board finds it significant that the 2017 private examiner did not report strength testing findings of the lower motor groups, after reporting testing of the upper extremity muscle groups. Further, while the 2017 examiner reported that the Veteran’s lower extremity reflexes were brisk, only the left ankle was reported to be absent. The Board notes that the Veteran has not been diagnosed with muscle atrophy of the left lower extremity and only the left foot indicated any reduction of muscle strength during this period. As such, the Board finds that the Veteran’s left lower extremity radiculopathy more nearly approximates “moderate” incomplete paralysis of the sciatic nerve from November 25, 2016. To the extent that the Veteran seeks a rating in excess of 20 percent for left lower extremity radiculopathy, the Board finds that the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 C.F.R. §§ 4.3, 4.7, 4.124a, DC 8520; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1991). Entitlement to a TDIU The Veteran seeks a total rating based on individual unemployability, claiming that he has been unable to work as a result of his service-connected disabilities. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to secure and follow substantially gainful employment. See 38 C.F.R. § §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board finds that the Veteran meets the schedular criteria for TDIU since November 7, 2011. From January 10, 2018, the Veteran has been service-connected for unspecified depressive disorder, rated 30 percent disabling; lumbar spine disability, rated as 20 percent disabling; and radiculopathy, left lower extremity (sciatic nerve), rated 20 percent disabling. The Board notes that these conditions have a combined disability rating of 60 percent and have a common etiology as they all have been granted based upon the Veteran’s lumbar spine disability. See 38 C.F.R. §§ 4.16, 4.25. From November 7, 2011 to January 9, 2018, the Veteran’s unspecified depressive disorder was rated, 70 percent disabling. Therefore, he meets the percentage requirements set forth in section 4.16(a) for consideration of TDIU from November 7, 2011. 38 C.F.R. §§ 4.16, 4.25. Thus, the next question for consideration is whether his service-connected disabilities prevent him from securing and following substantially gainful employment. The “applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner.” Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In November 2018, the Veteran submitted a VA Form 21-8940 (Veteran’s Claim For Increased Compensation Based On Unemployability). The Veteran reported that he had a high school education without any specialized training. He stated that he had stopped working in 2005 due to a combination of his back and psychiatric symptoms. The Veteran reported that his severe back pain was made worse by all attempts at employment since that time. For the following reasons, a TDIU is warranted. The Board finds probative the findings of the May 2010 VA examiner that stated that the Veteran was unemployed after previously working as a truck driver and a dairy farmer. The examiner noted that the Veteran stopped doing any of his occupations because he is unable to lift any weights and any movement of his neck or low back causes pain. The examiner stated that the Veteran was unable to stand or walk for extended periods of time beyond a half hour and that he is unable to drive due to his medications for his back pain. The examiner stated that the Veteran could perform basic activities of daily living, such as showering, putting on clothes and fixing meals for himself, but that beyond that lifting he is unable to do any household chores because of his limitations of movement. The Board also finds probative the findings of the January 2012 and January 2018 examiners that reported that the Veteran’s depressive disorder resulted in symptoms of depressed mood, chronic sleep impairment, and disturbances of motivation and mood that would impact his ability to perform non-sedentary employment. The Board notes that psychiatry records from the Gainesville VAMC indicate that the Veteran’s symptoms cause him to be irritable and moody most of the time and often interferes with his ability to get consistent sleep. The Board finds that the evidence of record reflects that the Veteran’s service-connected lumbar spine disability (along with its associated neurological impairments) and his depressive disorder preclude him from securing substantially gainful employment given his educational and occupational history. The Veteran’s pain and functional limitations due to his lumbar spine disability (and associated radicular symptoms) would preclude him from obtaining and maintaining substantially gainful employment, particularly his prior employment. The Board notes that the 2010 examiner indicated that the Veteran’s medications preclude him from performing his prior job as a truck driver. While there is some indication of overlap of limitations caused by the Veteran’s non-service connected neck condition and his lumbar spine condition reported by the 2010 examiner, the Board notes that the examiner indicated that the Veteran was unable to do any household chores beyond basic activities of daily living due to his lifting restrictions. The Board notes that when it cannot differentiate between the effects of a service-connected and nonservice-connected disorder, it must attribute the effects to the service-connected disability. See Howell v. Nicholson, 19 Vet. App. 535, 540 (2006) (explaining that the Secretary must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability); Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board notes that the 2018 examiner indicated that the Veteran’s back condition precluded all non-sedentary employment. The Board finds that the Veteran’s psychiatric symptoms that cause him to be irritable and moody most of the time, as well as, his recurrent pain due to his back condition would prevent him from being able to maintain the concentration and pace required for sedentary work. Accordingly, the Board finds that the Veteran’s lumbar spine disability (and its associated neurological impairments) and his depressive disorder have rendered him unable to secure or follow substantially gainful employment in light of his education and employment history. Therefore, entitlement to a TDIU is warranted. 38 C.F.R. § 4.16 (a). (Continued on the next page)   The Board will not specify the effective date of the TDIU to allow the RO to do so in the first instance. See Urban v. Principi, 18 Vet. App. 143, 145 (2004) (per curiam order) (“To the extent that [the appellant] is arguing that the Board must assign, sua sponte, an effective date once it awards a rating of TDIU on appeal from an RO decision, such an argument is unavailing unless an notice of disagreement is then of record as to the downstream issue of an effective date for the assignment of that rating.”) K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.M. Johnson, 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.