Citation Nr: 21021806 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-41 713 DATE: April 14, 2021 REMANDED Entitlement to service connection for a back disability (cervical or lumbar), previously claimed as an undiagnosed illness, and muscle spasms of the upper and lower back, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from August 1988 to August 1991. Most recently, the Board of Veterans’ Appeals (Board) remanded the issue on appeal for additional evidentiary development in November 2019. Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the appellant’s claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C. §§ 5107 (a), 5103A; 38 C.F.R. § 3.159 (c). Entitlement to service connection for a back disability (cervical or lumbar), previously claimed as an undiagnosed illness, and muscle spasms of the upper and lower back, is remanded. The Veteran maintains entitlement to service connection for a back disability (cervical or lumbar) that he avers is related to his active duty service. In September 2015, the Veteran underwent a VA examination where he was variously diagnosed with cervical spine strain and degenerative arthritis of the spine. The VA examiner opined that neither disability was related to service. Although there was record of neck and back pain in the Veteran’s service treatment records, the examiner noted that no additional service treatment records were available to demonstrate recurrent exacerbations and treatment; there was a lack of documentation supporting recurrent symptoms and treatment. The Board finds that the medical opinion is inadequate for adjudicatory purposes, as the examiner relied on a lack of documentation of treatment for recurrent symptomatology in service and did not consider the Veteran’s competent, credible complaints of back pain since service. Therefore, an addendum opinion is necessary. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's back disability (cervical or lumbar) is at least as likely as not related to service. The record shows that the Veteran was treated for neck and low back pain during service in 1990 and 1991, which he maintains has continued since service. A lack of documentation of complaints or treatment elsewhere in the STRs is not dispositive of the question as to whether the Veteran's current back disability (cervical or lumbar) is related to service. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bush 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.