Citation Nr: 21012384 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 18-13 360 DATE: March 4, 2021 REMANDED The claim of entitlement to service connection for degenerative arthritis and lumbar strain, to include as secondary to bilateral knee disorders is remanded. The claim of entitlement to service connection for a cervical spine disorder is remanded. The claim of entitlement to residuals of a fractured nose, to include chronic sinusitis is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1992 to January 1995. He testified at a virtual teleconference hearing in February 2021 before undersigned Veterans Law Judge (VLJ). It is contended that service connection is warranted for a lumbar spine disorder, a cervical spine disorder, and for residuals of head or neck trauma and/or fractured nose, to include chronic sinusitis. As for the lumbar spine disorder, it is asserted that the disability resulted from direct incurrence during active service as he was treated for back problems as indicated in his service treatment records (STRs) or as secondary to service-connected bilateral knee disorders (left knee patellar tendonitis and right knee degenerative arthritis). He has noted that he has worn a knee brace for many years. He believes that his gait disturbance has contributed to his lumbar spine disability. His cervical spine disorder is either also from inservice injury or as secondary to his service-connected headaches or sinusitis. He recalls that he fractured his nose during service and argues that his sinusitis resulted from that injury or from an in-service trauma to the head. (See, e.g. contentions made when examined by VA in 2016). A review of the STRs reflects that the Veteran was seen in April 1993 for reevaluation of a head injury after getting hit on the head with a tool. He was seen the following day and complained of a headache, a stiff neck, and middle back pain. The assessment was of muscle strain. Approximately, five days later, the Veteran was seen again for back pain after lifting heavy boxes. It was noted that he had been seen several days before and prescribed medications, but he his pain continued. There was tenderness with palpation on the right and left sides of the thoracic spine. There was full range of motion (ROM) with pain. The examiner’s impression was of back strain. In November 1994, the Veteran was seen for complaints of a pulled upper back muscle after lifting a 30-pound weight. There was tenderness to palpation on the left medial side of the upper back. Upper back strain was assessed. The STRs also include a June 1993 eye injury, to include the right maxilla, when the Veteran was hit in the face with M16 equipment. His vision was blurry and unstable. The right maxilla was slightly tender, but there was no evidence of fracture. A mild contusion was assessed. No fracture to the nose was reported at time of discharge. The STRs also include several instances when the Veteran was seen for nasal congestion, sinusitis, and headaches. Sinusitis of two weeks durations was noted in June 1994. He also reported sinusitis at time of discharge. Post service records include VA examination reports from 2016 which include diagnoses of low back and cervical disorders, as well as sinusitis. However, the examiners’ opinions as to etiologies of these disabilities are not favorable to the Veteran’s claims. Current Board review of the reports shows that not all in-service treatment records as summarized above were reviewed or discussed. Moreover, not all contentions now expressed by the Veteran have been adequately addressed by the current record. Additional VA examinations are warranted. It was noted at the recent hearing that additional pertinent records were also available and should be obtained. Remand is necessary to ensure that VA has met its duty to assist. 38 C.F.R. § 3.159(c)(4) (2020). The matters are REMANDED for the following action: 1. Obtain all updated relevant treatment records (private and VA) and associate them with the claim file. 2. Schedule the Veteran for a VA examination(s) with an examiner(s) of appropriate expertise to determine the etiology of any lumbar and cervical spine disorders. Based on a review of the electronic record and examination of the Veteran, the examiner(s) should: a) Provide opinions as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the claimed: (a) lumbar spine or (2) cervical spine disorders are causally or etiologically related to the Veteran’s active service. b) Provide opinions as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the claimed lumbar spine was caused by or are aggravated by service-connected bilateral knee disorders, or in the case of his cervical spine disorder, was caused by his service-connected headaches or nonservice-connected sinusitis. If a service-connected disorder aggravates the lumbar or cervical spine disabilities, the examiner(s) should identify the percentage of disability which is attributable to the aggravation. See 38 C.F.R. § 3.310 (2020). A complete rationale for any opinion expressed should be provided in a report. The Veteran is competent to report symptoms and treatment, and his reports must be taken into account, along with the other evidence of record. 3. Also, schedule the Veteran for a VA examination with an examiner of appropriate expertise to determine the etiology of chronic sinusitis. Based on a review of the electronic record and examination of the Veteran, the examiner should: a) Provide an opinion as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the claimed chronic sinusitis is causally or etiologically related to the Veteran’s active service. The examiner is requested to include discussion of the allegation that he suffered head trauma during service, to include a possible nose fracture, which resulted in sinusitis. Also, the examiner should discuss the numerous instances during service where the Veteran was noted to have sinusitis. b) Provide an opinion as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the claimed chronic sinusitis was caused by or are aggravated by service-connected headaches. If a service-connected disorder aggravates the Veteran’s sinusitis, the examiner should identify the percentage of disability which is attributable to the aggravation. See 38 C.F.R. § 3.310 (2020). A complete rationale for any opinion expressed should be provided in a report. The Veteran is competent to report symptoms and treatment, and his reports must be taken into account, along with the other evidence of record. 4. If upon completion of the above the issues remain denied, the file should be returned to the Board after compliance with appellate procedure. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Hal Smith, 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.