Citation Nr: 21026625 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-32 021 DATE: May 3, 2021 REMANDED Entitlement to service connection for cervical spine disability is remanded. Entitlement to service connection for lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to January 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the appeal in November 2018 in order to obtain an adequate opinion. VA obtained a medical opinion in November 2019 and the case has returned to the Board. 1. Entitlement to service connection for cervical spine disability is remanded. 2. Entitlement to service connection for lumbar spine disability is remanded. The Veteran contends he suffered an injury to his lumbar and cervical spine when he fell of his motorcycle on active duty. See June 2016 VA Form 9. With regard to both claims, the medical opinion VA obtained in November 2019 indicates the examiner could not locate this evidence because they found there was no indication of a motorcycle accident in the service record. See November 2019 Opinion. However, October 1978 service records show the Veteran sustained a right wrist navicular fracture due to falling of his motorcycle. See October 1978 Service Record. The Board finds the VA examiner's description of the service treatment record is factually inaccurate. The Board notes the examiner also failed to acknowledge cervical spine imaging results from June 1980 regarding the Veteran's complaints of right shoulder pain. See June 1980 Service Record. The Board notes that stamped on this imaging results report is the notation "no evidence of abnormalities," however, it is superimposed over the examiner's initials and is barely legible. This pertinent evidence should be considered on remand. Here, the Board finds the November 2019 opinion is factually inaccurate. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based upon an inaccurate factual premise has no probative value). For this reason, the Board finds this opinion is inadequate and additional opinion is necessary. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records. 2. Obtain an opinion, with an examination if necessary, by an appropriate clinician to determine the nature and etiology of cervical and lumbar spine disability. The examiner must address the Veteran's February 2016 contentions (contained on a June 30, 2016 VA Form 9) that his cervical and lumbar spine disabilities began in service and have resulted in chronic cervical and lumbar spine pain. The examiner should specifically note and discuss imaging results from June 1980 addressing complaints of "recurrent trap muscle spasm," a possible notation regarding "rule out neuropathy," and imaging findings of "no evidence of abnormalities." a. The examiner must opine whether it at least as likely as not (1) that a cervical spine disability began during active service, (2) or is due to in-service injury, including the October 1978 accident where the Veteran fell off his motorcycle. b. The examiner must opine whether it at least as likely as not (1) that a lumbar spine disability began during active service, (2) or is due to in-service injury, including the October 1978 accident where the Veteran fell off his motorcycle. The examiner must provide a thorough rationale for all findings, explaining in detail the reasons for the opinions rendered. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Trickey 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.