Citation Nr: 21029546 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-00 675 DATE: May 13, 2021 REMANDED Service connection for a lumbar spine disorder. REASONS FOR REMAND In September 2018, the Board reopened and denied an appeal for service connection for a lumbar spine disorder. The Veteran appealed to the Veterans Claims Court. In July 2019, the Court Clerk granted a Joint Motion for Partial Remand (JMPR) vacating a prior Board decision with regard to the claim on appeal. Subsequently, the Board remanded the case for further development pursuant to the JMPR on multiple occasions, most recently in December 2020. In a February 2021, a VA examiner opined that it was less likely than not that the Veteran's lumbar spine disorder was incurred in or caused either by service or by a service-connected condition, explaining that a causative nexus between a lumbar spine and right knee disorders was not supported by medical literature, pathophysiological models, or any documented evidence. The examiner noted that studies performed after the March 1990 fall revealed age-related changes along the lumbar spine that could not be attributed to an acute injury. Ultimately, the examiner opined that a lumbar spine disorder was a product of the natural aging process. The examiner further offered that the Veteran's obesity neither was a product of his service-connected right knee disorder nor aggravated his lumbar spine disorder beyond its natural progression, explaining that a causative nexus was not supported by medical literature. The examiner cited medical literature which found that the incidence of osteoarthritis was increased in obese individuals and constituted a major residual of obesity but reported that the Veteran was not diagnosed with lumbar osteoarthritis. However, the February 2021 examiner's depiction of the medical evidence does not accurately reflect the evidence of record. Specifically, while the examiner suggested that there was no documented evidence suggesting a nexus between a service-connected right knee disorder and lumbar spine disorder, clinicians reported in August 2000 and September 2016 medical treatment notes that the Veteran injured his back when his knee gave way, and that the fall exacerbated his chronic back pain. Similarly, the examiner's aggravation opinion as to obesity was based in part on the Veteran not being diagnosed with lumbar osteoarthritis; however, the record reflects that he was diagnosed with degenerative arthritis of his lumbar spine in an August 2014 VA examination. Additionally, as noted above, the February 2021 examiner found that it was less likely than not that the Veteran's obesity was caused by his right knee disorder or aggravated his lumbar spine disorder beyond its natural progression. However, the examiner did not specifically address whether the Veteran's obesity constituted an intermediate step between his service-connected right knee disorder and his lumbar spine disorder. Moreover, the examiner seemingly conflated the criteria for service connection based on aggravation with that for presumptive service connection under 38 C.F.R. § 3.309(a). Based on the above, the examination is inadequate for rating purposes. As such, regrettably, further development is again required in order to determine the nature and etiology of his lumbar spine disorder. The matter is REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records not already of record and associate them with the claims file. 2. Direct the claims file to a clinician to determine the nature and etiology of the Veteran's lumbar spine disorder. Based on a review of the record, the clinician is asked to opine as to whether it is at least as likely as not (a 50 percent probability or greater) that: (a.) The Veteran's lumbar spine disorder was directly caused or aggravated by service, to include the in-service development of an altered gait and wear and tear from long in-service road marches; (b.) The Veteran's lumbar spine disorder was caused or aggravated by a service-connected disability, to include his service-connected right knee instability; and (c.) The Veteran's obesity constitutes an intermediate step between his service-connected right knee disorder and his lumbar spine disorder. In forming the opinions, the clinician is asked to consider the August 24, 2000 and September 29, 2016 medical treatment notes and October 2017 lay testimony describing a nexus between the Veteran's lumbar spine disorder and his service-connected right knee disorder, as well as an April 2021 lay statement asserting that the lumbar spine disorder was the product of the in-service development of an altered gait and wear and tear from service. The clinician is advised that the Veteran's August 2014 VA examination reflects a diagnosis of degenerative arthritis of the lumbar spine and that, as such, a current diagnosis of lumbar degenerative arthritis has been established for purposes of eligibility for VA benefits. The clinician is reminded that obesity may qualify as an "intermediate step" between a service-connected disability and another current disability, and when found to constitute an "intermediate step" may suffice to establish a nexus between the two disorders. VAOPGCPREC 1-17 (2017). The rationale for all opinions must be provided. 3. If the clinician determines that an examination is necessary to provide the requested opinions, then it should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Spigelman, 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.