Citation Nr: 21026759 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-35 217 0DATE: May 3, 2021 REMANDED Entitlement to service connection for a lumbar spine disability to include coccygeal injury is remanded. Entitlement to service connection for left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1983 to September 1984. This matter comes before the Board of Veterans' Appeals from an October 2013 rating decision of the Department of Veterans Affairs Regional Office in Jackson, Mississippi, which denied entitlement to service connection for lumbar spine disability. While a February 2016 rating decision denied service connection for a right knee disability, the left knee disability was identified at the Board hearing as the knee for which the Veteran was seeking service connection. The Veteran testified before the undersigned Veterans Law Judge in September 2017. The matter was remanded by the Board in July 2018. As discussed below, there has not been substantial compliance with the July 2018 remand instructions, so the matter must be remanded again. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for lumbar spine disability and entitlement to service connection for left knee disability The record in this case shows the Veteran was in a motorcycle accident in service in March 1984. While her most serious injury was to her now service connected right ankle, the available service treatment records show she also sustained contusions along the sacrococcygeal area. Thereafter, in 1988 she was seen for pain in the coccygeal area, and in 1990 she was shown to have coccydynia, and a coccygectomy was accomplished in May 1990. Surgery records suggest this was considered to be associated with the in-service vehicle accident. More recently, a 2012 MRI showed lower lumbar spine mild disc disease and facet degenerative changes in the lower lumbar spine. This record shows an injury to the lower spine area in service. It also shows complaints and a surgical procedure to the lower spine area that occurred a few years after service, and a current disability located a few inches from where the surgery took place. The report obtained concerning the cause of the Veteran's current disability appears to acknowledge this history, but the rationale for concluding the Veteran's disability does not have a nexus with service does not adequately address the history. The rationale appears to be based on a limited view of the content of the medical records and does not contemplate the Veteran's report of on-going discomfort since the in-service accident that appears to have led up to the coccygectomy. Accordingly, another opinion should be obtained. In addition, there are minimal records from the period in the late 1980s and in 1990, when the Veteran was seen for lower spine complaints, and had the coccygectomy. The Veteran has indicated that her care at that time was through VA, thus, these records are in the VA's constructive possession. As such, remand is also necessary to attempt to retrieve these records. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim). Because a decision on the lumbar spine disability could significantly impact a decision on the issue of entitlement to service connection for a knee disability, the issues are inextricably intertwined. A remand for the claim for service connection for a left knee disability is, therefore, also required. Further, the examiner did not provide a complete rationale as to aggravation of the left knee. The rationale as to aggravation was essentially the same as the opinion as to causation and did not indicate if the Veteran's low back disability could have aggravated the Veteran's left knee disability. The matters are REMANDED for the following action: 1. Send the Veteran a letter asking her to identify all treatment providers for the issues on appeal and particularly for the period between 1984 and 1990. She should be requested to authorize VA to obtain available records for association with the claims file on her behalf. 2. Obtain and associate all relevant VA treatment records with the file, and particularly those as may date from 1984 to 1990, including inpatient and clinical records from that period. 3. Then, provide the Veteran's entire claims file to an appropriate examiner. The examiner should fully review the file, including the Veteran's testimony and statements about the onset of her low back disability. The examiner is specifically directed to the March 1984 report of the Veteran's in-service motorcycle accident, which indicated contusions to the sacrococcygeal area; the 1988 report of intermittent coccygeal pain since the in service accident; and her subsequent history. The examiner should identify the current lumbar spine disability or disabilities present, and provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current lumbar spine disability arose during service or is otherwise related to service, including the contusion to the sacrococcygeal noted in service. In providing the opinion, the examiner should indicate whether the Veteran's post service coccygectomy in 1990 was related to any in-service injury; whether the coccygectomy has any current residuals; and whether the coccygectomy could in-turn produce any other current disability. If the examiner determines that any lumbar spine disability is not related to service, the likely etiology of the Veteran's lumbar spine disability would be helpful for adjudication purposes. 4. If the examiner determines lumbar spine disability is causally connected to service, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's lumbar spine disability caused the Veteran's left knee disability or whether the Veteran's lumbar spine disability has aggravated the left knee disability beyond its natural progression. (Continued on the next page) 5. A rationale must be provided for all opinions, to include acknowledgement of the Veteran's lay statements. If the examiner cannot provide these opinions without examination of the Veteran, that should be arranged. 6. Thereafter, readjudicate the issues on appeal. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Geer, Associate 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.