Citation Nr: 21013787 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 15-14 415A DATE: March 10, 2021 REMANDED Entitlement to service connection for a cervical spine disability, to include as secondary to a service-connected bilateral hips disability, is remanded. Entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected bilateral hips disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1983 to June 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Pittsburgh, Pennsylvania. These claims were previously before the Board in November 2018 and September 2020. Although the Board sincerely regrets the additional delay, it finds that another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a cervical spine disability, to include as secondary to a service-connected bilateral hips disability, is remanded. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected bilateral hips disability, is remanded. The Veteran underwent a VA examination in September 2019. At that time, the examiner opined that the Veteran’s cervical spine disability is most likely multifactorial due to age, wear and tear, extremely common in people over sixty years of age and is therefore less likely than not caused by in service event or injury. The examiner explained that there were no records indicating trauma or repeated complaints of neck pain, as there is only one record of cervical strain without repeated visits indicating chronic pain as well as the separation examination being negative for such. The examiner also opined that the Veteran’s lumbar spine disorder is less likely than not caused by in service event. The examiner explained that there is no evidence of progressive and repetitive injury to the back and although there is a documented episode of lumbar strain during a sporting event, there are not repetitive treatment notes indicating continued or further disability in light of the Veteran’s exit examination being silent on any further back problems. First, the Board notes that while the September 2019 examiner noted that there is only one record of cervical strain without repeated visits and no repetitive treatment notes indicating continued or further disability for back problems, a review of the Veteran’s service treatment records (STR) reflects that such statement is not completely accurate. A May 1985 STR reflects a note of symptoms in which the examiner indicated started in the neck and back. A January 1988 STR reflects a note of the Veteran’s complaint of lower back pain. An assessment of low back strain is noted. An April 1988 STR reveals that the Veteran pulled a muscle in neck area after playing softball, with a note of mild tenderness of cervical area. Additionally, the last x-ray the examiner noted was from June 2005. However, the record reflects that 2010 private x-rays of the Veteran’s back were associated with the claims file in November 2011. Opinions based on inaccurate facts, particularly when the inaccurate facts are directly related to the basis of the opinion, have no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Additionally, in a December 2012 statement, the Veteran indicated his neck problems started a couple of years after service, but he did not seek treatment until 2000. Thus, the examiner appears to have not given consideration to the Veteran’s lay statements. Therefore, the September 2019 examination as it pertains to the question of direct service connection contains inaccurate facts and is thus inadequate. Pursuant to the Board’s September 2020 remand, opinions concerning secondary service connection were obtained in October 2020. At that time, the examiner provided unfavorable opinions as to proximate causation and aggravation of the Veteran’s cervical and lumbar spine disabilities by his service-connected bilateral hip condition. Specifically, in regard to the lumbar back disability, the examiner rationalized that the hip and back pain symptoms appeared in relative time frame to each other and both have progressed with time. The examiner found that there was no direct evidence that the lumbar spine disease was significantly worsened by the hip degenerative changes and has progressed over twenty years. Paramount, as the examiner rationalized that there is no direct evidence of aggravation for either disability, the Board notes that in December 2020, x-rays from November 2020 were associated with the claims file which show findings of a cervical spine with severe osteochondrosis and a lumbar spine with severe osteochondrosis. The Board notes that the October 2020 examiner was not afforded review of such medical evidence that shows severe osteochondrosis. The Board is unable to determine the significance, if any, of such findings in regard to whether there is direct evidence of significant worsening by a service-connected disability. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Thus, remand is appropriate to obtain an addendum opinion which addresses the x-ray findings. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion with respect to the disabilities of the Veteran’s cervical and lumbar spine. The claims file and a copy of this remand must be made available for review. The need for another clinical evaluation is left to the discretion of the medical professional offering the addendum opinion. A qualified clinician should be asked to review the record and provide an addendum opinion which directly addresses whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disabilities of the Veteran’s cervical and/or lumbar spine have been aggravated by his service-connected hip disabilities, to include as a result of altered gait mechanics. In doing so, the examiner is asked to address the Veteran’s service treatment records showing multiple neck and lumbar complaints; the Veteran’s lay statements, particularly the December 2012 statement indicating that his neck problems started a couple of years after service, but that he did not seek treatment until 2000; the April 2010 x-ray records; and the November 2020 x-ray findings showing severe osteochondrosis of the cervical spine and lumbar back. A complete rationale for all opinions should be provided. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Alli, 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.