Citation Nr: 21016092 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 14-31 887A DATE: March 19, 2021 REMANDED Entitlement to service connection for a low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1981 to March 1984, from May 1984 to June 1987, a three month period of active duty for training in 1988, again on active duty from October 2008 to October 2009 with additional Reserve service until June 2010. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The issue was previously remanded by the Board in August 2018 to obtain a new VA examination and to address the Veteran’s in-service and post-service complaints of back pain. Unfortunately, another remand is necessary to ensure compliance with the prior remand. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a low back condition The Veteran’s service treatment records reveal that the Veteran went to sick bay and was placed on light duty as a result of an injury when unloading a truck. The Veteran’s service treatment records also reveal complaints of low back pain following an in-service assault. An October 2011treatment report reveals that the Veteran was involved in a motor vehicle accident and complained of neck and lower back pain. In a VA examination in August 2013, the Veteran reported that he injured his back when he was unloading a truck. The examiner noted a diagnosis of degenerative joint disease of the lumbar spine with an onset date of August 2013. The examiner opined that it was less likely than not that the Veteran’s low back condition was related to military service. The Veteran was afforded a VA examination in June 2014. Again, the examiner noted a diagnosis of degenerative disc disease. The examiner opined that the condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there was no evidence of a back segmental injury in service to link his degenerative disc disease, degenerative joint disease, and scoliosis. The examiner noted that the evidence of the Veteran’s condition related to his neck segment and did not overlap with his thoracic back segment. The examiner also stated that there no evidence of a back injury from his parachute related badge and jumps or his injury from unloading a truck in service. The examiner noted that the more likely etiology was related to his post-service October 2011 motor vehicle accident. The August 2018 Board remand specified that the examiner must address the Veteran’s lay statements pertaining to an in-service assault, an injury sustained while unloading a truck, undergoing parachute training, and carrying heavy gear while marching. The Veteran underwent a new VA examination in July 2019. The examiner diagnosed subjective lumbar pain. She indicated that the Veteran was diagnosed with degenerative arthritis of the lumbar spine and scoliosis of the lumbar spine in the past due to a minimal lumbar series of plain radiographs dated August 8, 2013. She went on to explain that a computed tomography (CT) scan was performed on October 22, 2013 and revealed no spondylosis and no scoliosis. She determined that the diagnoses of degenerative changes and scoliosis were made prematurely. She concluded that “with 28 years of the Veteran’s lumbar spine revealing no changes (assault being in 1985 and last CT in October 2013), any current changes would be due to natural age progression….” While the examiner mentioned the Veteran’s assault, she did not address the Veteran’s other lay statements outlined in the prior Board remand, including discussion of an injury sustained while unloading a truck, parachute training, and carrying heavy gear while marching. Additionally, the history set forth in the 2019 VA examiner’s opinion does not appear to be complete. For example, the examiner indicated the October 2013 CT exam did not reveal spondylosis or scoliosis. However, the CT scan did note that disc bulge or foraminal narrowing can be found at L3-4 and at L5-S1 it was noted “there may be mild disc bulge centrally.” These findings were not addressed by the examiner. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of any low back disability. The examiner must address the following: Provide a diagnosis for any low back disability demonstrated during the period on appeal, to include found on examination or otherwise in the record. The clinician must consider the entire claims file, including the October 2013 CT scan, which reflected that “disc bulge or foraminal narrowing can be found at L3-4” and at L5-S1 it was noted “there may be mild disc bulge centrally.” The August 2018 Board remand outlines relevant evidence including two previous VA examinations. It is briefly summarized above. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the clinician should consider them a “disability” for the purpose of providing the requested opinion. For any low back disability, provide an opinion as to whether it is at least as likely as not that the condition had its onset during the Veteran’s service or is otherwise etiologically related to the Veteran’s service. In doing so, the clinician must address the Veteran’s in-service and post-service complaints of back pain. The examiner must specifically address the Veteran’s lay statements pertaining to an in-service assault, an injury sustained when unloading a truck, undergoing parachute training, and carrying heavy gear during marches. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Vemulapalli, 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.