Citation Nr: 21026705 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-15 324 DATE: May 3, 2021 ORDER Entitlement to service connection for a back disability as secondary to a service-connected heart condition is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran's back disorder was caused or aggravated by his service-connected heart condition. CONCLUSION OF LAW The criteria for service connection for a back disorder as secondary to service-connected heart condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to April 1988. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran properly perfected the appeal. See September 2014 Notice of Disagreement; February 2016 Statement of the Case; and March 2016 Substantive Appeal (VA Form 9). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in February 2019. A transcript of that hearing is of record. In May 2019, the Board remanded the claim for further development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a back disability secondary to the service-connected heart condition is denied. The Veteran seeks service connection for a back disability secondary to his service-connected heart condition. Specifically, he asserts that he collapsed during an August 2013 heart attack and hurt his back. In this regard, the Board notes that the Veteran does not contend direct service connection. Thus, the Board will limit its analysis to secondary service connection only. The relevant medical evidence of record includes a VA examination and VA treatment records, which the Board will discuss chronologically. Notably, the Veteran has an extensive history of medical treatment relating to his back. Specifically, x-rays of the lumbar spine, performed in December 2000, revealed mild narrowing of the posterior aspect of the L4-L5 disc which were noted to be normal for the patient or that may have represented early degenerative disc disease. A December 2009 VA treatment record shows that the Veteran had chronic back pain and recent onset right hip pain. At the time of treatment, the Veteran reported that his hip pain had decreased. A March 2009 physical therapy treatment note documents low back pain with left leg sciatica. An October 2011 MRI showed facet arthropathy, degenerative disc disease, and spinal stenosis (stenosis particularly L4-5), but reports did not indicate the severity. A November 2012 VA treatment record reveals that the Veteran presented with complaints, in relevant part, of chronic back pain. The Veteran reported that he did not have lower extremity weakness or paresthesias. A November 2013 VA treatment record shows that the Veteran had chronic low back pain and radiculopathy and was taking medication to relieve his pain. A June 2013 VA treatment record reveals that the Veteran presented with complaints of back pain. The Veteran also reported that he had radicular symptoms down his right leg. An August 2013 MRI revealed distal thoracic and mid to distal lumbar generative disc and joint disease with moderate spinal canal stenosis at L4-L5. Another August 2013 VA radiology report also shows that the Veteran underwent an MRI of his lumbar spine. The examining clinician noted that the Veteran had lumbar radiculopathy and that a prior MRI showed spinal stenosis and facet arthropathy worse at L4-L5. Impressions revealed distal thoracic and mid to distal lumbar generative disc and joint disease with moderate spinal canal stenosis at L4-L5. An additional August 2013 record, dated on the same day that the Veteran suffered his myocardial infarction, shows that the Veteran complained of radiating pressure to his arms and back. The clinician also noted a past medical history, in relevant part, of sciatica and degenerative lumbar spinal stenosis. At the time of treatment, the Veteran reported that he felt like he passed out but that he did not know for how long. A November 2013 VA treatment record revealed further complaints of chronic back pain. In December 2013, the Veteran had another MRI which revealed a herniated disc. An October 2014 VA treatment record reveals that the Veteran had a long history of chronic pain, most intense in the low back, followed by the knees and less so in the hands. The clinician also noted that the Veteran had an MRI of the lumbar spine in August 2013, just days before his heart attack, in which he reported degenerative joint disease; degenerative joint disease; and spinal stenosis of varying degrees. The clinician also noted that the Veteran's low back pain became much more intense after his fall with radiation to the left leg. An August 2015 VA treatment record reveals that the Veteran underwent an L4/5 laminectomy and bilateral L4/5 medial facetectomies two months prior. Radicular pain was noted to have improved. The clinician noted that the Veteran's pain was constant with varying degrees of severity, and that pain was worse with yardwork and as the day progressed. Pain was alleviated by medication. There was no reported numbness, tingling, focal muscle weakness or incontinence of bowel/bladder. In May 2019, service connection was granted for the Veteran's heart condition. Also, in May 2019, the Board remanded the claim relating to the back for a medical opinion to specifically determine whether the Veteran's back disorder was secondary to his newly service-connected heart condition. The Veteran was afforded a VA examination in November 2019, at which time the examined noted a diagnosis of chronic thoracolumbar spine strain with degenerative arthritis and spinal stenosis status post lumbar laminectomy, as well as spinal fusion. The Veteran also reported that he fell in 2013 after he collapsed following a myocardial infarction and that the next day, he had back soreness and stiffness, as well as limited motion due to pain. The examiner opined that it was less likely than not that the Veteran's back condition was caused by or incurred by a fall related to a myocardial infarction and mitral valve prolaps. The examiner determined that the more likely etiology was the Veteran's post-service job in missile repair, which was noted to be physically demanding, and that his condition was the natural progression to his diagnosis. During the examination, the Veteran also reported that he had thirty years of chronic back pain, but that it always went away or calmed down after flareups. The examiner acknowledged the Veteran and his wife's prior statements that he had not been having back pain prior to the August 2013 fall from the myocardial infarction. The examiner also cited to the Veteran's lengthy treatment for back-related issues, to include a diagnosis of L4-5 degenerative changes in 2000 and years of epidural steroid injections. The examiner also noted that the Veteran suffered chronic back pain in 2009 at which time the Veteran was seen for physical therapy and had taken back to his chronic baseline with back pain and sciatica. The examiner also cited to 2011 treatment records in which the Veteran was seen for chronic back pain and underwent an MRI for known degenerative arthritis and spinal stenosis. The examiner also reported that in 2015, the Veteran underwent a lumbar laminectomy for spinal stenosis. The Veteran reported that this helped and that he could stand and no longer had symptoms going down his leg, but instead had moderate back pain that comes and goes. The examiner noted that a baseline level of severity could not be determined because the Veteran had a long-standing history of chronic back pain. The examiner also opined that it was less likely than not that the Veteran's back condition was aggravated beyond its natural progression. The examiner reasoned that the examination revealed mild thoracolumbar spine strain with degenerative changes and spinal stenosis, which was the same condition seen over the past decade. The examiner also noted that the Veteran had evidence of pain, termed chronic in 2009, and that the natural progression for the Veteran's back condition at the examination, even without any falls, was "exactly where he should be" and that he had minimal progression from his 2000 symptoms. The examiner further noted that there was no evidence that the Veteran's fall changed any of his symptoms that he previously had, prior to his fall, and therefore no aggravation was found for the prior chronic back problem that started years ago. Here, there is no medical evidence of record indicating that the Veteran's back disorder is linked to his service-connected myocardial infarction (heart condition). Instead, in November 2019, the VA examiner opined that it was less likely than not that the Veteran's back disorder was proximately due to or the result of his service-connected heart condition, noting that the Veteran had a long-standing history of back pain and varying back disorders, citing the Veteran's medical history. The examiner also opined that the Veteran's back condition was not aggravated beyond its natural progression by a fall caused by his heart disorder. In this regard, the examiner acknowledged the Veteran and his wife's statements and his medical history, but still concluded that there was no established nexus or aggravation due to the fall following his heart attack. When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric, respiratory, or orthopedic disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Additionally, the Veteran is competent to report pain, because it is a lay-observable sensation. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran is not competent to render an etiology opinion for his back condition. Determining the etiology of the Veteran's back disorder requires medical inquiry into orthopedic processes and functioning. Such internal processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As to the Veteran's wife's statements, the Board finds that she is credible in saying that the Veteran did not complain to her of low back pain prior to his fall; however, as with the Veteran she is not competent to address causation. Because the Veteran's and his wife's lay opinions are not competent to establish a nexus in this case, they are not probative and cannot satisfy the nexus element of a service connection claim. The Board also acknowledges the November 2014 clinician's statement that the Veteran's low back pain became much more intense after his fall with radiation to the left leg. Because there is no evidence that the clinician assessed whether the Veteran's back disorder was permanently aggravated beyond the normal progression or determined a baseline of severity, and did not provide a rationale for his statement, the Board affords greater probative weight to the November 2019 opinion. The Board finds the most probative evidence to be the opinion of the November 2019 VA examiner, who provided sound reasons and bases that the Veteran's back condition was not caused or aggravated by a fall following a heart condition. In this regard, the examiner relied on the Veteran's lengthy medical history surrounding his back and relied on the Veteran's prior complaints to clinicians for the purpose of medical treatment. The examiner also determined the more likely etiology for the Veteran's back condition using sound medical rationale. As such, the preponderance of the evidence is against the claim and service connection for a back condition as secondary to his service-connected heart condition is denied. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hanson, 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.