Citation Nr: 21024380 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 16-11 288A DATE: April 22, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for spinal fusion, claimed as a low back disorder, is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1977 to August 1981. Most recently, the Board remanded the claim in September 2020 to the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The case has since been returned to the Board for appellate review. Unfortunately, a remand is required again in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure the Veteran is given every possible consideration. 1. Service connection for a neck disability is remanded. The Board finds that the February 2021 VA medical opinion is inadequate as the examiner did not address the Veteran’s lay contentions of neck pain since falling during active service. Further, the examiner incorrectly stated that the Veteran did not report a neck injury during active service; however, as noted in the September 2020 remand, the June 1980 STR noted that the Veteran fell down some stairs and reported spine pain for three months. While the STRs appear to reference low back pain, the Board also noted that the Veteran has provided sworn testimony that he injured his neck in the same incident. See June 2019 Board testimony at p. 31. Therefore, the AOJ should obtain additional medical opinion to address whether the Veteran’s neck disorder was caused by active duty service. 2. Service connection for a spinal fusion is remanded. The Board finds that the February 2021 VA medical opinion is inadequate as the examiner did not address the Veteran’s lay contentions of back pain since falling during active service. Further, the examiner incorrectly stated that the Veteran did not report a back injury during active service; however, as noted in the September 2020 remand, the June 1980 STR noted that the Veteran fell down stairs and reported spine pain for three months. Therefore, the AOJ should obtain additional medical opinion to address whether the Veteran’s back disorder was caused by active duty service, specifically addressing the Veteran’s competent statements indicating back pain during and since service. 3. Service connection for headaches is remanded. The Board finds that the February 2021 VA medical opinion is inadequate as the examiner did not address the Veteran’s competent lay statements regarding the presence of headaches since falling during active service. During his June 2019 Board hearing, the Veteran stated that his headaches began after he fell and hit his head, neck, and back. Also, in a February 2014 statement, the Veteran noted that during service he hit his head, lost consciousness, and has had headaches since. Therefore, the AOJ should obtain additional medical opinion to address the significance of the Veteran’s statements indicating headaches during and since service. The matters are REMANDED for the following action: 1. Obtain a VA addendum opinion pertaining to the etiology of the Veteran’s claimed neck disability. Based on a review of the record, the examiner should opine whether it is at least as likely as not that a current neck disability is etiologically related to an in-service injury, event, or disease, including the Veteran’s reported in-service fall. The examiner should address the Veteran’s contention that he has had continuous neck pain since service, as well as the Board hearing testimony. Also, the examiner must provide a complete rationale for all opinions expressed and conclusions reached. 2. Obtain a VA addendum opinion pertaining to the etiology of the Veteran’s claimed back disability. Based on a review of the record, the examiner should opine whether it is at least as likely as not that the condition (1) began during active service; (2) is related to any in-service event or injury; or (3), for arthritis only, manifested within one year of active duty service. The examiner should address the Veteran’s contention that he has had continuous back pain since active service, as well as address his multiple reports of lower back pain during active service. Further, the examiner must address the report of an old vertebrae injury, as described during the Veteran’s June 2019 Board hearing. Lastly, the examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. Obtain a VA addendum opinion pertaining to the etiology of the Veteran’s claimed headaches. Based on a review of the record, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not that headaches are related to any in-service disease, event, or injury, to include the Veteran’s reported in-service fall or head impact with a boiler valve. (b.) If it is determined that the Veteran’s current back and/or neck disability is of service origin, whether it is at least as likely as not that a current headache disorder is proximately due to, or aggravated by, a service related back or neck disability. The examiner should address the Veteran’s contention that he has had continuous headaches since active duty that he treated with over-the-counter medication. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Costello, 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.