Citation Nr: 21015326 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 14-34 087 DATE: March 17, 2021 REMANDED Entitlement to an initial rating in excess of 20 percent for a thoracolumbar spine disorder prior to November 3, 2015, and in excess of 40 percent thereafter, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1988 to August 1988, and from March 1990 to April 1996. 1. Entitlement to an initial rating in excess of 20 percent for a thoracolumbar spine disorder prior to November 3, 2015, and in excess of 40 percent thereafter, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for a thoracolumbar spine disorder. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2018, the Board remanded this claim and included the following instruction: The examiner should also determine the extent of any neurological impairment related to his thoracolumbar spine disorder, specifically addressing the Veteran’s July 2017 hearing testimony indicating shoulder symptoms and bilateral lower extremity lumbar radiculopathy symptoms. During a March 2019 VA examination, the examiner noted that the Veteran reported constant left lower scapular pain, but did not offer an opinion as to whether this pain is related to the Veteran’s thoracolumbar spine disorder. The examiner did indicate that imaging of the Veteran’s spine was not available for review. In November 2019, the Board again remanded this claim and instructed the examiner to address the following: [T]he extent of any neurological impairment related to the thoracolumbar spine disorder, specifically addressing the Veteran’s July 2017 hearing testimony indicating shoulder symptoms and opining as to whether any shoulder pain is etiologically related to the thoracolumbar spine disorder[.] (Emphasis in the original.) During a December 2019 VA examination, the examiner noted that shoulder pain is typically related to a cervical spine disorder rather than a thoracolumbar spine disorder. However, the examiner did not address the Veteran’s testimony or specifically address the Veteran’s shoulder pain, but rather addressed shoulder pain in general. Additionally, it appears that actual imaging results are still not associated with the claims file. The December 2019 VA examiner noted that the latest imaging completed on April 2019 was unavailable for review; and in September 2020 a different VA examiner also noted an impression recorded by a previous VA examiner regarding thoracolumbar spine imaging, but it is unclear if the September 2020 VA examiner reviewed the actual imaging results. The Board notes that the Agency of Original Jurisdiction granted service connection for radiculopathy of the lower extremities related to the thoracolumbar spine disorder in August 2019. A remand is needed to obtain an additional VA medical opinion that adequately addresses the Veteran’s claim of shoulder pain related to his service-connected thoracolumbar spine disorder. The matters are REMANDED for the following action: 1. Obtain VA treatment records since September 2020 and associate them with the claims file. Additionally, obtain the results of the April 2019 imaging of the Veteran’s thoracolumbar spine and associate them with the claims file. 2. Forward the Veteran’s claims file to a qualified examiner for an opinion addressing any neurological impairment of the Veteran’s upper extremities related to his service-connected thoracolumbar spine disorder. The examiner must specifically address the Veteran’s July 2017 hearing testimony indicating constant pain in the shoulder blades and opine as to whether any shoulder pain is etiologically related to the thoracolumbar spine disorder in this particular case. The examiner must also opine as to whether there is any medical reason to accept or reject the Veteran’s belief that his shoulder symptoms are the manifestations of his current thoracolumbar spine disorder. (Continued on the following page.) If an examination is needed to provide the opinions requested or to obtain current imaging of the thoracolumbar spine for the examiner’s review, one should be scheduled. A complete rationale must be provided for any opinion offered. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.