Citation Nr: 21029127 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-11 275 DATE: May 12, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1958 to April 1962. Entitlement to service connection for a low back disability is remanded. The Veteran asserts that his current low back disability is related to service, specifically, to his in-service surgical excisions. In a December 2014 statement, the Veteran reported that during his in-service surgical excision, he had to lie down on his stomach so everyone could see the redness that had spread out on his back, as it was as big as a volleyball. He reported that everyone came to see his odd presentation, that 14 months later, he had the same problem and experienced a more severe surgical excision, and that upon separation from service he was not told what was wrong with his back, but that that he had a solid mass in the small of his back confirmed by his family physician 32 years ago. In his April 2015 Notice of Disagreement (NOD), the Veteran asserted that he had surgery on two occasions during service and was discharged due to the disabling effects of such. In his March 2016 Substantive Appeal, the Veteran reported that his back had given him trouble since his in-service surgery and has worsened since. The Veteran's service treatment records dated in February 1959 indicate that a mole on his trunk, posterior (beltline), was excised. In October 1960, he was diagnosed with cellulitis, without lymphangitis, perianal, and presented with complaints of a tender mass to the left of the anus for two months, relatively asymptomatic save for occasional tenderness. He sought treatment for diarrhea and was referred to treatment for the cellulitis. The Veteran's past medical history and review of symptoms were entirely unremarkable; physical examination revealed a linear tender induration on the left buttock just beyond the region of the anus, without communication found to the rectum, slightly tender on palpation. He underwent incision and drainage, had a benign post-operative course, and was discharged to duty well-healed. In February 1962, the Veteran presented with a two and one-half months history of a draining pilonidal sinus tract. The treatment provider noted that he had a previous procedure done for a pilonidal cyst in 1960; his past medical history and review of symptoms was unremarkable. Physical examination revealed the presence of a pilonidal sinus tract, the large cyst was excised, and the resultant defect was left open to heal. He healed well and was discharged fit for duty. His March 1962 service separation examination report was silent for any related disability and included a notation that the Veteran was released from active service, transferred to the Reserves, and able to perform all duties. VA treatment records dated in as early as May 2009 indicate that he complained of a history of arthritis in the back, with degenerative joint disease seen on films presently. A June 2009 VA treatment note indicates that magnetic resonance imaging (MRI) revealed degenerative disc disease and lumbar stenosis. VA treatment records dated in April 2014 indicate that the Veteran complained of a two-week history of right-sided back pain, into the side of his buttock. VA treatment records dated in August 2017 were silent as to any abnormality found on physical examination of the back. In a March 2015 Disability Benefits Questionnaire (DBQ), the Veteran was diagnosed with degenerative arthritis of the spine, osteoarthritis, 2009. The Veteran reported that in 1960, during service, he experienced tenderness to the buttocks area and was evaluated, which revealed a rectal abscess. He reported that his condition was treated by later continued as a diagnosed pilonidal cyst which was surgically removed. He complained of low back pain attributed to his in-service treatment and excision of the cyst and anal fistula. The examiner opined that it was less likely than not that the Veteran's low back disability is related to his in-service removal of his pilonidal cyst. The examiner reasoned that the Veteran's cyst was removed in 1962, and it was unlikely than such occurred at the beltline, as medical literature shows that these cysts are skin disorders, taking place in the tailbone, coccyx, or proximal to the cleft of the buttock, with most of the cysts appearing to be caused by loose hairs penetrating the skin causing pain to the coccyx and buttock area. The examiner discussed that no medical literature supports the conclusion that arthritis is related to these cysts or excision. The examiner noted that the Veteran's service treatment records also demonstrated that he had a mole excised at the beltline, however, again, no medical literature supports the conclusion that excision of a mole causes arthritis. The examiner noted that MRI results showed degenerative changes, osteoarthritis, and medical literature indicates that such is generally a result of years of normal wear and tear but could also be hastened by genetically inherited conditions or spinal injury. While the examiner discussed the medical literature pertinent to pilonidal cysts, further medical comment is required. On remand, the Department of Veterans Affairs (VA) Region Office (RO) should afford the Veteran a new VA examination of his low back disability and obtain an etiological opinion that specifically addresses the nature of the Veteran's in-service complaints and treatment, as well as his lay statements of in-service and post-service low back pain. As the Veteran reported, in his December 2014 statement, that he had a solid mass in the small of his back confirmed by his family physician 32 years ago, and it does not appear that such a mass has been noted by any treatment provider or examiner, it remains that there may be outstanding relevant private treatment records. On remand, the AOJ should afford the Veteran an opportunity to supplement the record with such, with any private treatment records showing a solid mass in the small of his back. Also, the most recent VA treatment records available for Board review are dated in October 2018; on remand, the RO should obtain and associate with the claims file the Veteran's updated VA treatment records. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 2018 to the present. 2. Ask the Veteran to complete VA Forms 21-4142 for any outstanding relevant private treatment records, specifically, any private treatment records demonstrating a solid mass on the small of his back. Make two requests for the authorized records from any identified and authorized private treatment provider unless it is clear after the first request that a second request would be futile. 3. Then, schedule the Veteran for a VA examination for his low back disability. The examiner must review the claims file. The examiner is asked to provide a response, with complete rationale, to the following: (a) Is the Veteran's low back disability at least as likely as not (at least 50 percent probability) related to service, including his in-service February 1959 excision of a mole on his trunk, posterior (beltline), his October 1960 excision for cellulitis, without lymphangitis, perianal, and/or his February 1962 excision of a pilonidal cyst? In this regard, the examiner must specifically consider and discuss: (1) the anatomical location of the Veteran's in-service mole, cellulitis, without lymphangitis, perianal, and pilonidal cyst specifically as it relates to the proximity of the low back; (2) the Veteran's general state of health as recorded upon discharge from surgical treatment during service and on his March 1962 service separation examination report as it relates to his assertion that he was discharged from service due to the disabling effects of his surgical excisions; (3) the Veteran's lay statement that he had or has a solid mass on the small of his back; (4) the Veteran's lay statement that at the time of his first in-service surgical excision, he had redness that had spread out on his back, as big as a volleyball; and (5) and the Veteran's lay statements of in-service and post-service low back pain as it relates to the March 2015 DBQ comment that pilonidal cysts can cause pain to the coccyx and buttock area. (b) For low back arthritis, it is at least as likely as not (at least 50 percent probability) that such: (1) manifested to a compensable degree within one year of separation from service; or (2) was noted during service with continuity of the same symptomatology since service, considering the Veteran's lay statements of in-service and post-service low back pain? In providing the requested opinions, consider the Veteran's description of his in-service symptoms and treatment as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms and treatment in service and thereafter represented the onset of his current disability, this should be noted. (Continued on the next page) Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Department of Veterans Affairs 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.