Citation Nr: 21014978 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 18-50 793 DATE: March 16, 2021 REMANDED Entitlement to service connection for a lumbar spine disability, to include degenerative disc disease and degenerative arthritis, is remanded. REASONS FOR REMAND The Veteran had active service from January 1986 to January 1990. He had additional duty with the Naval Reserve. In August 2019, the Board of Veterans’ Appeals (Board) denied service connection for a back disability. The Veteran subsequently appealed to the United States Court of Appeals for Veteran Claims (Court). In June 2020, the Court granted the Parties’ Joint Motion for Remand; vacated the August 2019 Board decision; and remanded the appeal to the Board for additional action consistent with the Joint Motion for Remand. Entitlement to service connection for a lumbar spine disability, to include degenerative disc disease and degenerative arthritis, is remanded. The service treatment records reflect that the Veteran was seen on multiple occasions for lifting injuries, chronic low back pain, mechanical low back pain, and radiating lumbar spine pain. A January 1987 treatment record states that the Veteran was seen for sciatica. A January 2015 physical evaluation from R. Mohr, M.D., states that the Veteran underwent a September 2014 lumbar spine laminectomy. Clinical documentation of the cited treatment is not of record. VA clinical documentation dated after November 2020 is not of record. The Department of Veterans Affairs (VA) should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The report of a January 2021 spine examination conducted for VA states that the Veteran was diagnosed with lumbar spine intervertebral disc syndrome, degenerative arthritis, and bilateral lower extremity radiculopathy. The examiner concluded that “the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness” as “there is no objective evidence of chronicity of care from 1990 until 2013 when he injured his back at work, a nexus has not been established.” The nurse practitioner did not note the absence of relevant clinical documentation for review or address the relationship between the documented in service radiculopathy and the diagnosed bilateral lower extremity radiculopathy. Therefore, the Board finds that the examination report is of essentially no probative value. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA spine evaluation is needed. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for any lumbar spine disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Associate with the record any VA medical records for treatment provided after November 2020 not already of record. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor to ascertain the nature of any identified lumbar spine disability and any relationship to active service. The examiner must review the record and should note that review in the report. The examiner should: (a) Identify all lumbar spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that any identified lumbar spine disability had its onset during active service or is related to any incident of service, including the Veteran’s documented in service chronic low back pain and sciatica. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C.Ivan Franklin 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.