Citation Nr: 21013828 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-30 120 DATE: March 10, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1974 to October 1978. This case comes to the Department of Veterans Affairs (VA) Board of Veterans’ Appeals (Board) from an Agency of Original Jurisdiction (AOJ) rating decision dated in March 2011. This case was before the Board most recently in October 2020, at which time it was remanded to the AOJ for further development. Unfortunately, for the reasons set forth below, another remand is required. 1. Entitlement to service connection for a back disability is remanded. The AOJ obtained a supplemental VA opinion in November 2020. The opinion is based on incorrect information, making it inadequate. First, the examiner indicated that there was no evidence that the Veteran complained of a back condition within a year of separation. However, a VA treatment note dated in January 1979 shows that the Veteran complained of low back pain, which he reported had begun 6 to 8 months prior. A diagnosis was not made, but sciatica and “probable” lumbar disc prolapse needed to be ruled-out. An examiner must address this record in an adequate opinion. Second, the examiner wrote that the Veteran’s service treatment records (STRs) “are silent for any trauma or injury to the back.” As noted in prior remands, the Veteran was diagnosed with a muscle strain in September 1975 and a pulled muscle in August 1978, and low back pain was noted in April 1977 and June 1978. Third, the examiner indicated that the Veteran had an injury to his back before enlisting, which was reported in his enlistment physical. However, the Veteran’s enlistment physical indicates he responded “no” when asked about recurrent back pain, and while he reported having been in a motor vehicle accident and having had a dislocated shoulder previously, the Veteran did not report a preexisting back disability, nor was one noted. For these reasons, a remand is required. The matters are REMANDED for the following action: 1. Forward the record including a copy of this remand to a qualified examiner for completion of an addendum opinion. Following review of the record, the examiner should respond to the inquiry below.. The examiner should address the following: (a.) The examiner must specifically address and discuss the Veteran’s contention that he had at least one existing back condition that developed or was incurred during service that was aggravated by a post-service car accident and/or 1995 work injury. In doing so, the examiner should clarify the June 2019 VA examination conclusions that, “minor car accident at least as likely as not may increase the back pain and aggravated the back condition…[and] the lifting accident…at least as likely as not aggravated his ddd,” and indicate whether the post-service accidents and injuries aggravated a disability that was incurred in service. (b.) The examiner must address and discuss the following evidence: September 1975, April 1977, June 1978, and August 1978 STRs regarding low back pain; and a January 1979 VA treatment record regarding a complaint of low back pain. (c.) The examiner must address the contention that the MRI machine was invented in 1977 or 1978, and was not available to military providers or in commercial use to have been able to have diagnosed disc prolapse at the time, and the Veteran did not just have myofascitis or strain, which was indicated by the Veteran’s prescribed bed rest and restricted duty in service. (d.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s arthritis was incurred in, or manifested within a year of, active duty service. (Continued on the next page)   A complete rationale must be provided for all expressed opinions. A complete explanation for all opinions expressed must be provided. A clearly stated rationale must not be based solely on lack of documentation or records. The reasons for any opinion must include a discussion of the relevant evidence. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Smith, 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.