Citation Nr: 21022738 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-50 419 DATE: April 19, 2021 ORDER Entitlement to service connection for lumbosacral degenerative disc disease is granted. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, the Veteran’s low back disability is causally related to his military service. CONCLUSION OF LAW The criteria for service connection for lumbosacral degenerative disc disease have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from November 1992 to August 1996. Thereafter, he served in the Naval Reserve until November 2004. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). When this case was last before the Board in December 2019, it was remanded for additional development. The case has now been returned to the Board for further appellate consideration. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing direct service connection generally requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for a low back disability The Veteran contends that his current low back disability is related to injuries he sustained while in service. The Veteran was diagnosed with degenerative arthritis of the spine with lumbosacral degenerative disc disease and lumbar radiculopathy in January 2014, satisfying the criteria for a current disability. The Veteran’s service treatment records reflect treatment for back pain. Specifically, in 1994 he slipped and fell on his tailbone during a training operation. The next day he fell out of his bunk, landing on chairs. He indicates he has suffered from mid to low back pain since these events. Although the Veteran’s separation examination does not include complaints of low back pain, private treatment records from September through November 1996 reflect treatment for the low back, noting limited range of motion and lumbosacral subluxations and soreness. Furthermore, the Veteran stated he did not mention all of his health problems at the separation examination because he just wanted out of the Navy and to go home and move on. See C&P Exam received January 2020. In 2012, the Veteran was found to have an L4-S1 disc herniation. The Veteran also underwent back surgery in 2017. See VA examination received February 2018. The Veteran was afforded a VA examination in January 2020, in which the examiner opined the Veteran’s low back disability was less likely than not due to his military service. The examiner’s rationale was based on no diagnosis, only complaints of back pain, noted in service. The examiner further stated low back pain is not causally linked to the development of lumbar spine degenerative disc disease because degenerative disc disease refers to a syndrome in which age-related wear and tear on a spinal disc causing low back pain, and everyone experiences some disc degeneration. The examiner further stated that while degenerative disc disease causes low back pain, low back pain does not cause degenerative disc disease. The examiner did not provide supporting medical evidence for this opinion. Thus, the Board affords this opinion little probative value. Although the January 2020 examination is the most recent one, the Veteran previously provided a private medical opinion in January 2018. The examiner opined it is at least as likely as not that the Veteran’s lower back condition began during service and has continued uninterrupted to present. While the examiner did not address the Veteran’s silent service treatment records, he does thoroughly address the Veteran’s in-service injuries, treatment immediately after service, and diagnoses, providing adequate rationale for his opinion. Based on the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s lumbosacral degenerative disc disease is causally related to his military service. Thus, with the benefit of the doubt resolved in the Veteran’s favor, a grant of service connection for lumbosacral degenerative disc disease is warranted. B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Townsend, 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.