Citation Nr: 21026470 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-17 588 DATE: May 3, 2021 REMANDED Entitlement to service connection for a lumbar spine condition is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1974 to March 1978. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, a hearing was held before the undersigned. A transcript of the hearing is of record. The case was previously before the Board in September 2018 when it was remanded for further development. Lumbar Spine Condition In the September 2018 remand, the Board determined that the January 2013 VA examiner's opinion was inadequate as the examiner found that the Veteran's lumbar spine condition was less likely than not incurred in or caused by service, including a March 1974 fall down stairs and February 1975 fall out of a tree but only provided a conclusory rationale that there was insufficient documentation to demonstrate chronicity of low back pain while in service or in the intervening years since separation until 2004. The Board directed that the Veteran be afforded a new VA examination in this case. The examiner was directed to opine as to whether it is at least as likely as not that the Veteran's lumbar spine condition is related to any event during service, including a March 1974 fall down stairs, a February 1975 fall out of a tree, and December 1976 complaints of back pain. The examiner was also directed to consider the Veteran's lay statements regarding the onset of his disability, including his July 2018 testimony before the Board, where he stated that he was experiencing back pain during service and when he got out of service and it continued to worsen since then. The Veteran underwent a VA examination in November 2019. The examiner indicated that the Veteran was diagnosed with degenerative arthritis of the spine. The examiner then opined that the Veteran's degenerative arthritis of the spine was less likely than not related to service. The examiner stated that the service treatment records were remarkable for a "self-limited and acute back pain" after a fall episode with no evidence of chronic pathology of the spine during service. The separation examination in February 1978 was normal and post-discharge, there was no medical evidence of chronic pathology of the spine proximate to service. Initial imaging in 2008 showed osteophytic spurring, which was greater than 30 years after service, Should there be any documentation of chronic spine pathology within the proximate period of military discharge then it should be made available for review by the examiner and another opinion would be rendered. However, the examiner, in rendering this opinion, did not consider the Veteran's statements regarding his back disability. A medical opinion that does not consider all relevant evidence of record, including lay statements, is inadequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Also, the examiner stated that the Veteran had "self-limited and acute back pain," after a fall episode, the examiner did not discuss the subsequent incidents of back problems noted in the service treatment records. Furthermore, the fact that the Veteran's condition was normal at discharge does not preclude service connection being granted for a post-service condition if it is, in fact, related to the service injury. As such, remand is necessary to obtain an addendum medical opinion that sufficiently considers the evidence of record. Additionally, all updated VA treatment records from April 2020 to the present should be obtained and associated with the claims file. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from April 2020 to the present. 2. Forward the Veteran's claims file to the examiner who completed the November 2019 VA back examination for an addendum medical opinion. If the VA examiner who provided the November 2019 opinion is not available, then forward the Veteran's claims file to an appropriate VA clinician to obtain a medical opinion on the below question. The complete claims file and a copy of this Remand must be made available to the reviewing clinician. If another examination (or telehealth interview, if an in-person examination is not feasible) of the Veteran is deemed necessary by the clinician providing the opinion, one should be scheduled. Based on the review of the entire record and a copy of this Remand, the clinician should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's lumbar spine condition is related to any event during service, including a March 1974 fall down stairs, a February 1975 fall out of a tree, a June 1976 notation of low back pain, and December 1976 complaints of back pain. The examiner must discuss the significance of all these in-service incidents. The opinions should address the particulars of this Veteran's medical history and the relevant medical principles as applicable to this claim. The examiner must also consider and discuss the Veteran's lay statements regarding the onset of his disability, including his July 2018 testimony before the Board, where he stated that he was experiencing back pain during service and when he got out of service and that it continued to worsen since then. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bonnie Yoon, 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.