Citation Nr: 21024946 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 14-14 311 DATE: April 27, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served active duty from March 1976 to May 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The claims were remanded in November 2015, July 2019, and April 2020 for further development. Specifically, the RO was instructed to attempt to obtain service treatment records from the Orlando Naval Hospital. The claims have now been returned to the Board for appellate review. The Board notes that the original appeal included a service connection claim for a psychiatric disability, including post-traumatic stress disorder (PTSD). In an October 2020 rating decision, the Veteran was granted service connection for PTSD. The decision is considered a full grant of benefits. Ab v. Brown, 6 Vet. App. 35 (1993). Therefore, that issue is no longer in appellate status. 1. Entitlement to service connection for a cervical spine disability, a low back disability and hypertension. The Veteran has asserted that his claimed disorders are related to his military service. In several statements, the Veteran has reported that he injured his neck and back while doing a high jump during basic training or boot camp in May 1976. See February 2011 statement. In his March 2011 VA Form 21-4142, the Veteran reported that he injured his neck and back at the naval training center and the pain has worsened over time. VA treatment records and private treatment records show the Veteran has been evaluated and treated for hypertension, a cervical spine disability, and low back pain. A January 2016 letter from a VA physician indicated the Veteran injured his back and neck during his military service while in Orlando in 1976, and that in 2008 the injury was aggravated by another incident. As noted above, the claims were remanded for the RO to obtain records from the Orlando Naval Hospital. In a January 2021 note of unavailability, VA was informed that the records had been archived at National Personnel Records Center (NPRC) after the hospital closed in 1995. The Board notes that on prior occasions, VA has attempted to obtain the records from NPRC but was informed that the records had not been retired to Code 13. Thus, it appears the Veteran’s service treatment records are unavailable or lost. In cases where some of the claimant’s service records may be unavailable through no fault of the claimant, there is a heightened obligation to assist in the development of the case. O’Hare v. Lewinski, 1 Vet. App. 365 (1991). To date, the Veteran has not been afforded a VA examination in connection with his claims. In light of the evidence of record, and the heightened duty to assist with the development of the claim, the Board finds that the Veteran should be afforded VA examinations and medical opinions to determine the nature and etiology of any hypertension, cervical spine disability, or low back disability that may be present. For the reasons stated above, remand is necessary for further development. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed low back disability. The examiner should answer the following: a) Identify any current low back disorder. b) For all identified disabilities, is it at least as likely as not (a fifty percent probability or greater) that the diagnosed low back disability is causally related to his service, to include any injury or symptomatology therein? Attention is invited to the Veteran’s February 2011 statement that he injured his back while participating in a high jump exercise during basic training (labelled “VA 21-4138 Statement In Support of Claim” – uploaded 2/25/2011). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed cervical spine disability. The examiner should answer the following: Is it at least as likely as not (a fifty percent probability or greater) that the cervical spine disability is causally related to the Veteran’s active service? Attention is invited to the Veteran’s February 2011 statement that during service the Veteran performed a high jump and missed the mat, landing on his neck, shoulder, and back (labelled “VA 21-4138 Statement In Support of Claim” – uploaded 2/25/2011). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed hypertension. The examiner should answer the following: Is it at least as likely as not (a fifty percent probability or greater) that hypertension is causally related to the Veteran’s active service? A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.