Citation Nr: 21028387 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 03-32 330 DATE: May 11, 2021 REMANDED Entitlement to service connection for residuals of injury to the lumbar spine is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from May to July 1979. This appeal has a lengthy procedural history, including multiple Board remands with the most recent in February 2019, Board decisions in October 2010 and November 2013, and grants of Joint Motions for Remand and Partial Remand by the Court of Appeals for Veterans Claims (Court) in May 2011 and November 2014. Notably, in the Joint Motion for Partial Remand, which was the subject of the November 2014 Court Order, the parties agreed that the issue of entitlement to service connection for degenerative disc disease of the lumbar spine should not be disturbed on remand. Thus, the appeal before the Board includes all potential diagnoses other than degenerative disc disease of the lumbar spine. 1. Entitlement to service connection for residuals of injury to the lumbar spine is remanded. Although the Board regrets further delay, remand for a new medical opinion is needed to best adjudicate the claim. Prior Court and Board remands have focused on whether VA has satisfied the duty to assist in obtaining treatment records from the Veteran's service. However, in prior decisions, the Board found that the records available were sufficient to establish that the Veteran had a low back injury in service. Specifically, records from Carswell Air Force Base and Brookes Army Medical Center show multiple complaints of back pain and reports of the incident of being kicked in the back while attempting to stop a fight. These records show an intravenous pyelogram with x-ray was obtained on June 19, 1979, to rule out any damage to the Veteran's kidney from the reported incident. Treatment summaries from June 25, 1979, show diagnosis of psychophysiologic musculoskeletal disorder, left lower back, chronic, moderate, stable, treated conservatively. Moreover, during the March 1999 VA examination, the Veteran reported being diagnosed in service with back strain. The question remaining is whether this in-service injury at least as likely as not resulted in a current disability of the lumbar spine (other than degenerative disc disease). The March 1999 VA examiner diagnosed degenerative disc disease of the lumbar spine and provided a negative opinion for that diagnosis. Therefore, the March 1999 opinion has limited probative value as to any diagnosis other than degenerative disc disease. The May 2009 VA examiner opined that the current low back problem is less likely than not related to the 1979 in-service injury. Although the examiner discussed the Veteran's history of treatment, he did not provide rationale or explanation for this negative conclusion. A new examination and medical opinion are needed to adequately assess the Veteran's claim. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Additionally, the record shows the Veteran attempted to complete an authorization to release medical records to VA. However, in multiple letters, the Agency of Original Jurisdiction (AOJ) explained that the forms could not be processed because they did not include a signature and date. Despite these letters, the Veteran's representative continued to submit the undated copy of the form. The Board notes that the Veteran/representative should submit a copy of the form that is signed and dated by the Veteran in order for the release to be processed. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA and/or private treatment records. Provide the Veteran with an authorization to release medical records. The Veteran is advised that both a signature and date are required for the authorization to be processed. 2. Schedule the Veteran for a VA examination and medical opinion for his low back. The examiner should review the claims file and address whether any current low back disability (including the May 2009 examiner's diagnosis of osteoarthritis of the lumbar spine but excluding degenerative disc disease) is at least as likely as not related to the in-service incident of being kicked in the back with diagnoses of back strain and psychophysiologic musculoskeletal disorder, left lower back, chronic. In this regard, the examiner should note that a low back injury in service has been conceded. The examiner should consider all relevant lay and medical evidence, including the Veteran's reports of continuous back pain since service. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the examiner should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.P. Armstrong 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.