Citation Nr: 21030227 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 09-50 651 DATE: May 18, 2021 ORDER Entitlement to service connection for a lumbar spine disorder, diagnosed as lumbar degenerative disc disease and lumbar laminectomy and discectomy, is granted. Entitlement to service connection for right lower extremity radiculopathy as secondary to the Veteran's service-connected lumbar spine disability is granted. FINDINGS OF FACT 1. The Veteran's lumbar spine disorder, diagnosed as lumbar degenerative disc disease and lumbar laminectomy and discectomy, is at least as likely as not related to active service. 2. The Veteran's right lower extremity radiculopathy is attributable to his service-connected lumbar spine disability. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for a lumbar spine disorder, diagnosed as lumbar degenerative disc disease and lumbar laminectomy and discectomy, have been met. 38 U.S.C. § 1101, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The Veteran's right lower extremity radiculopathy is proximately due to, or the result of, his service-connected lumbar spine disability. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Navy from December 1985 to July 1997. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision. The record shows that in a May 2011 decision, the Board reopened the Veteran's previously denied service connection claim for a low back disorder and remanded the issue to the agency of original jurisdiction (AOJ). The Board later remanded the case again in a September 2014 decision. In an April 2017 decision, the Board denied the Veteran's service connection claim for a lumbar spine disorder. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2017 Order, the Court vacated the Board's decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Remand (Joint Motion). In an August 2018 decision, the Board remanded the case once more to the AOJ. The case has since been returned to the Board for appellate review. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in November 2020. A transcript from that proceeding is associated with the claims file. 1. Entitlement to service connection for a low back disorder, to include as secondary to service-connected degenerative disc disease, C3-4 and C4-5. 2. Entitlement to service connection for right lower extremity radiculopathy. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). The Veteran contends that he has a lumbar spine disorder that is directly related to his active service. The record has also raised the theory that the disorder is secondary to the Veteran's service-connected cervical spine disability. During service, the Veteran's November 1985 enlistment examination noted that his spine was normal on clinical evaluation, and no relevant defects were noted. The Veteran also denied having any history of recurrent back pain in the November 1985 Report of Medical History. Although he reported a history of broken bones, the physician's summary indicates that this report was made in reference to a right wrist fracture. A subsequent December 1989 reenlistment examination did not note any abnormalities in the Veteran's spine, and the Veteran did not report any pertinent problems in the December 1989 Report of Medical History. In September 1994, a service examination was also silent for any spine abnormalities. The Veteran continued to deny recurrent back pain in the September 1994 Report of Medical History. On November 27, 1995, a service treatment record (STR) stated that the Veteran complained of pain from the base of his neck to about his mid-shoulder blade in relation to an "injury" on November 20, 1995. There was no known reason for aggravation apart from possibly painting the patio of the house. The Veteran had also experienced a tingling sensation in his fingers since a 1987 head/neck injury. The assessment was trapezius/cervical strain. On November 29, 1995, the Veteran was seen for a follow up of cervical strain after being seen on November 27, 1995. He was doing better with a decrease in sharp pain. The assessment was resolving cervical and upper back strain. An associated consultation was requested on this date, and the provisional diagnosis was upper back and cervical strain. The November 30, 1995 consultation report noted that the Veteran had experienced cervical and upper back pain since November 21, 1995. He complained of a constant burning sensation in the bilateral cervical paraspinous upper trapezius and the upper back muscles. The assessment was acute upper back and cervical strain. On December 4, 1995, an STR noted that the Veteran complained of upper back pain that emanated out of the back between the shoulder blades and radiated up into the neck on both sides. The assessment was cervical and upper back strain. The Veteran was noted to be doing much better and December 6, 1995, and the assessment was resolving cervical and upper back strain. On December 14, 1995, an STR noted the Veteran's report that his neck and upper back pain was 95 percent resolved. The assessment was neck pain resolved. On January 8, 1996, an STR noted that the Veteran had experienced an onset of upper back pain and neck stiffness two days earlier. The assessment was recurring cervical upper back strain. A consultation was requested on this date, and the January 11, 1996 consultation report noted that no injury preceded the episode of neck pain and upper back strain on January 6, 1996. The assessment noted that there were decreased complaints of pain with treatment, and the etiology was unknown. On January 25, 1996, an STR noted under the assessment that a trial of cervical spine traction increased symptoms; and the Veteran now had chronic neck and upper trapezius pain. On March 14, 1996, an STR reported that the Veteran had a recurrent history of neck/back pain. He was requesting Naprosyn until his orthopedic appointment that Monday. On April 8, 1996, a Report of Medical Board noted that the Veteran presented with acute neck pain since November 1995. He reported having an episode of neck pain after a cruise box fell on his head in 1987. The pain went away at that time. Since November 1995, the Veteran's chief pain has been neck pain with occasional tingling in the digits of both upper extremities. The Veteran reported very occasional pain radiating down into the bilateral shoulders and arms, on the right greater than the left. There was no loss of bowel or bladder function, history of erectile dysfunction, or reported sensory or motor abnormalities in the lower extremities. The summary diagnosis was degenerative joint disease of the cervical spine with evidence of old C4 compression fracture that did not exist prior to enlistment. The Medical Board recommended that the Veteran be placed on six months of limited duty. A plan was made to follow up with the spine clinic in two months. On February 25, 1997, the orthopedic spine clinic noted that the Veteran presented with a long history of neck pain, right shoulder and arm pain, and mild dysesthesias in the right fifth finger. The Veteran was unable to move his head without pain, and he could not walk long distances or perform shipboard work. The diagnoses were degenerative disc disease C3-4, 4-5, 5-6; spondylolisthesis C3 on C4; and right arm pain. A February 25, 1997 Medial Board Report Cover Sheet noted diagnoses of degenerative disc disease of the cervical spine at C3-4, C4-5, and C5-6; severe, unrelenting neck pain; and bilateral upper extremity arm pain, right greater than left. A March 1997 separation examination did not note any abnormalities in the Veteran's spine. In a March 1997 Report of Medical Assessment, the Veteran reported that his overall health was worse when compared to his last examination and reported persistent neck and arm pain. The healthcare provider comments noted a history of a neck fracture. In a March 1997 Report of Medical History, the Veteran marked the category to report a history of recurrent back pain. However, "neck" was written next to the category. He also reported swollen or painful joints; broken bones; arthritis, rheumatism, or bursitis; and bone, joint or other deformity. The physician's summary noted that all of these reports, including recurrent back pain, corresponded to degenerative joint disease C4/neck fracture. On June 8, 1997, an emergency care and treatment record from the Naval Medical Center in San Diego, California noted that the Veteran's chief complaint was lower back pain. He reported twisting his back while hiking the previous day. A separate June 8, 1997 STR noted that the Veteran complained of pain in the tailbone of the low back after hiking down a steep hill. His wife reported that his low back was swelling up. The assessment was lower back strain. After service, an October 1997 VA general medical examination noted that the Veteran had been experiencing progressively increasing neck pain over the past four years. In addition, he had low back pain that he attributed to his neck. He also had pain in the dorsal spine. The noted diagnosis was history of neck injury. The examiner noted that the Veteran had a history of degenerative joint disease of the spine diagnosed in the Navy with current limitations of the cervical spine. He did not have any lower extremity signs except for brisk bilateral knee jerks and ankle jerks which might show long track lesions. An associated October 1997 VA lumbar spine x-ray noted in the impression that there was no evidence of bone or joint pathology. The intervertebral disc spaces appeared to be of normal height. In July 1999, a VA medical certificate noted that the Veteran complained of low back pain radiating to the bilateral lower extremities for one day status post increased activity the previous day. The Veteran had been sliding down a waterslide, but he denied experiencing direct trauma to the back. Regarding his past medical history, the record indicated that he was discharged from the Navy due to cervical and lumbar spine problems. The diagnostic impression was probable degenerative disc disease and acute lower back pain. In October 2000, a private treatment record reported that the Veteran had pain all over his back from his shoulder blades to his low back and down his legs. The assessment was neck and upper back pain. On October 25, 2000 a private treatment record noted that there was wedging of the anterior surface or portion of the vertebral body of L1, old, and indicating a very mild probable post traumatic compression fracture. There was no evidence of spondylolysis or spondylolisthesis. The impression was old posttraumatic compression changes of L1, possible T12. A subsequent November 8, 2000 entry noted low back pain and numbness in the lower extremities. On November 27, 2000, a record noted that the Veteran had a new onset of back pain after skiing on November 24, 2000. The pain had been present with right leg numbness and buttock pain that was now spreading to the left buttock. The assessment indicated that the Veteran had a herniated disc in the lumbar spine. A plan was made to obtain a lumbar spine MRI. A separate entry from November 27, 2000 noted that the Veteran's first significant low back pain began two years ago. The onset of low back pain at that time was possibly related to an injury sustained on a water slide. During the past two years, he had experienced occasional low back pain which had not been severe. His current symptoms began one month ago with a sudden onset of severe low back pain. The record stated that recent radiographs of the lumbar spine revealed no significant abnormalities. An MRI of the lumbar spine performed on that date showed degeneration at L5-S1 with decreased signal and normal spine alignment. There was a large and contained central portion to the disc herniation which filled approximately 50 percent of the spinal canal. There was a large extruded disc fragment which was displaced in a cephalad direction lying in the right side of the spinal canal to the L5 vertebral body. There was also extrinsic compression of the right L5 nerve root, and the sacral roots were displaced and compressed. The assessment was right sciatica and mild/early cauda equina injury secondary to large L5-S1 disc herniation and extrusion. That same day, the Veran underwent a right L5 hemilaminectomy with L5-S1 discectomy and decompression of the right side of the spinal canal which was displaced in a cephalad direction causing significant and extrinsic compression of the cauda equina, and compression of the right S1 nerve root. In January 2001, a private treatment record noted that the Veteran was status post L5-S1 diskectomy for right sciatica and mild/early cauda equina injury. The record noted that the Veteran had a good outcome with improvement in his sciatica and improvement in the mild cauda equina injury. His back pain was related to degenerative changes in the lumbar spine. In November 2004, a VA treatment record stated that the Veteran had low back pain for a week that had been severe for four days after grouting the tiles on his kitchen floor. The record stated that he had a history of low back pain for more than four years. He had a laminectomy in November 2004 that was helpful, and he was seen two years ago with left sciatica. A lumbar spine MRI noted an impression of herniated nucleus pulposus L5/S1 with displaced cauda equina. Sequestered fragment not included. The assessment was left sciatica. In April 2005, noted that the Veteran's pain improved after his lumbar spine operation in 2000, but he had left lower extremity pain two years later related to weeding in the yard. The pain resolved before he had another episode in November 2004 that again resolved. There was currently no pain in the left lower extremity and no numbness, tingling, or strength loss. The assessment noted that the Veteran had a prior L5-S1 laminectomy with left-sided disc herniation recurrent at that level. Although he did have two episodes of pain that sounded consistent with the left sacroiliac root, he was now asymptomatic. In January 2007, a VA treatment record noted that the Veteran reported having recurrent back pain with radiation, but he was fine at the time of the visit. The record noted that a diagnosis of degenerative disc disease in the back and neck. In July 2007, a private treatment record noted that the Veteran was unable to move his neck without pain after going down a water slide. The record did not note low back pain in relation to the water slide injury. In June 2008, a VA treatment record stated that the Veteran had missed approximately 12 to 15 days of work for the past 12 months due to his neck and low back problems. In September 2008, a VA lumbar spine MRI noted that conus medullaris terminated at T12-L1 and was normal. The cauda equina was unremarkable. The Veteran was status post right L5 laminectomy and posterior decompression. There was posterior peripheral granulation tissue/scar. There was no significant intracanalicular enhancement. The marked L5-S1 disc height loss and broad posterior bulge were unchanged. The small central posterior disc protrusion was slightly decreased in size compared to the prior examination, and there was no evidence of sequestered disc fragment. The epidural fat or scar deviated from the inferior thecal sac and inferior equina to the right posterior aspect of the canal into the region of the right L5 laminar decompression, with indeterminate effect on the sacral roots. The remaining intervertebral disc heights and signal were within normal limits, without evidence of significant disc bulge, canal stenosis, or foraminal narrowing. In October 2008, a VA treatment record noted an assessment of chronic back pain. In a May 2008 statement, the Veteran reported that he began to have neck problems almost immediately after retiring from the Navy in August 1997. The problems gradually worsened until he had part of a disc removed in his low back. The Veteran reported that his low back and sciatic nerve continued to bother him a daily basis. In the August 2009 notice of disagreement, the Veteran reported that he had experienced low back problems since service. The Veteran indicated that he had been out for days for a back spasm after the June 1997 in-service injury. In an April 2010 statement, the Veteran noted that the back spasm he experienced in service was just as severe as the one he suffered during his post-service waterslide accident. The Veteran also reported that since approximately 1990, he experienced sharp pains that ran down his leg if he stepped hard on his foot. The Veteran attended a VA examination related to his claim in January 2010. Regarding the Veteran's low back disorder with sciatica, the examiner noted the Veteran's reported history that the onset of his lumbar spine condition occurred in the early 1990's during active duty service with no specific injury. He noted that during his active service, twisting motions or awkward stepping on uneven surfaces would cause sharp back pains at times that could last for several minutes and would occur 3 to 4 times a month. The Veteran recalled that after the June 1997 documented treatment for his low back strain, his spasms continued for three days before resolving. The Veteran also reported that before his November 2000 lumbar spine surgery, he had constant pain, weakness, stiffness, fatigability, and lack of endurance with radiation of the pain down the back of his right leg associated with weakness in dorsiflexion and plantar flexion as well as numbness in the bottom of his foot. After the surgery, he had residual numbness in the plantar aspect of his right heel and intermittent pain with occasional radiation down the back of the right leg. He currently had intermittent pain with weakness, stiffness, fatigability, and lack of endurance. The diagnosis was lumbar spine degenerative joint and degenerative disc disease with residual L5 painful sensory radiculopathy on the right, as evidenced by objective numbness over the right posterior/plantar aspect of the heel and intermittent radiating pain down the back of the right leg, in addition to the September 2008 MRI findings documenting marked L5-S1 disc height loss and broad posterior bulge. The Veteran was status post L5-S1 laminectomy and discectomy in November 2000. The January 2010 examiner opined that it was less likely than not that the Veteran's current lower back condition was caused by or the result of his military service. There was evidence of low back strain during military service, but no evidence of a chronic lumbar spine condition that led to the Veteran's current lumbar spine degenerative joint disease/degenerative disc disease. The one documented self-limited episode of low back pain while the Veteran was on active duty was not accompanied by prior or subsequent complaints of low back pain during service. There was also a normal lumbar spine examination and lumbar spine x-ray 3 months after the Veteran's separation from active duty service. The examiner additionally noted the normal findings in the March 1997 separation examination, the report in the November 2000 record that the Veteran's onset of low back pain occurred two years earlier in conjunction with a waterslide injury, and the November 2000 record's finding that the acute onset of severe pain in October 2000 was consistent with acute herniated disc. The examiner noted that the historical record provided good evidence that the Veteran had a self-limited back strain during military service that resolved, and that his current lumbar spine condition was caused by either the waterslide injury after military service or the October 2000 period when he likely acutely herniated his L5-S1 disc. Another VA examination related to both the cervical and lumbar spine was conducted in September 2011. Regarding the Veteran's low back disorder, the examiner indicated that the relevant history was well-documented in the January 2010 VA examination. The Veteran further reported that after the in-service injury to his cervical spine, he had a sharp onset of low back pain that lasted for a few minutes and resolved whenever he stepped up a step or moved in a rotated position. The examiner also observed that a March 1996 STR noted recurrent neck and back pain with an examination focused on the cervical spine. The diagnosis was lumbar strain with history of L5-S1 laminotomy discectomy without evidence of residual radiculopathy on physical examination. The examiner did not provide a medical opinion. Another VA examination related to the Veteran's claim was conducted in January 2020. Regarding his in-service medical history, the Veteran informed the examiner that that he only sought medical care for his back and neck when the symptoms were very severe. He indicated the June 1997 record of documented treatment was for a very severe back injury. The Veteran also reported frequently carrying heavy loads during service such as groceries, ammunition, and heavy test equipment in his role as an electronics technician. The Board notes that the Veteran DD 214 reflects that his primary specialties included duties as a surface high frequency communication system maintenance technician and shipboard maintenance technician. The Veteran also described having back pain when he was in service that had continued since that time. The Veteran indicated that the June 1997 episode of treatment occurred after he fell down a ravine while hiking. He went to the hospital the next morning after having significant back pain and being unable to get out of bed. The Veteran recalled that it took about a week to recover from this injury. The Veteran noted that the injury happened before his separation, but after his March 1997 separation examination. Approximately eight months after his separation, he went down a slide at a water park and had back pain that led to him sitting out the rest of the day at the park. He woke up the next day with back pain in the same location that he had previously experienced pain and could not get out of bed. Later in November 2000, he was skiing and had a lot of pain in his legs after just a few runs. He recalled that he lost bowel and bladder function prior to having a laminectomy and discectomy. The Veteran reported having back pain since that time. The diagnoses were lumbar degenerative disc disease, right lower extremity radiculopathy, and lumbar laminectomy and discectomy. The January 2020 VA examiner provided a negative nexus opinion. The examiner opined that the Veteran's lumbar spine disorders were less likely than not due to any in-service related injury or to his in-service duties. The examiner noted that there were two very thorough medical opinions of record that clearly outlined the medical evidence, which showed that there was some low back pain first reported in June 1997 after falling while hiking. No imaging was taken at the time, and there is no mention of any back problems any earlier in the record. The examiner then appeared to reference the post-service October 1997 VA examination, which the examiner noted as occurring in December 1997. The examiner highlighted the October 1997 VA examination's report that the Veteran "also has low back pain which he ascribes secondary to his neck. He also has pain in the dorsal spine," and the fact that the lumbar spine examination at that time was normal. The examiner stated that there was clear evidence over the subsequent years (after separation) of injuries that led to back problems (skiing injuries, a waterslide injury, etc.). The Veteran had a lumbar laminectomy/discectomy in November 2000 due to a disc herniation. The examiner found it significant that the note at that time stated that the Veteran's first significant low back pain occurred two years ago. The onset of his low back pain at that time was possibly related to the injury sustained on a water slide. During the past two years he had experienced occasional low back pain which had not been severe. His current symptoms started one month ago when he had the sudden onset of severe low back pain. The examiner noted that the prior opinions dated in 2010 and 2016 had concluded that there was no chronic lumbar disability from the Veteran's period of service and that his lower back conditions were the result of injuries/events after his separation. The examiner then appeared to reference the August 2018 Board remand instructions as also reflecting the same conclusion. In this regard, the Board notes that the August 2018 Board remand directives asked the examiner to opine as to whether it is at least as likely as not that the Veteran's lumbar spine disorder had its onset during service or was in any way causally or etiologically related to his active service. The Board also requested for the examiner to address the June 1997 in-service injury to the low back as well as the Veteran's assertion that his job as an electronic technician during service caused him to be bent over a work bench for extended periods of time and affected his lumbar spine. As such, the instructions did not reflect any conclusion regarding the Veteran's theory of direct service connection and the examiner's reference to the instructions as evidence in support of her conclusion is misplaced. In addition, the October 2016 VA medical opinion that was highlighted by the January 2020 examiner was limited to addressing the aggravation prong of secondary service connection. In the rationale to support the negative opinion, the October 2016 examiner noted that although the record showed intermittent exacerbations of the cervical spine condition and the lumbar spine condition, the record was silent for any discussion by a medical professional attributing a permanent worsening of the lumbar spine condition due to the cervical spine condition. There were multiple entries in the medical record which showed exacerbations of the Veteran's lumbar spine condition that were directly related to his physical activities, including hiking, water sliding, a fall on the ice, a motor vehicle accident in 2008, and prolonged walking after his car broke down. All these activities were independent of the Veterans neck condition. Notably, the October 2016 examiner's subsequent listing of the records that supported her opinion reflects that the October 2016 examiner's discussion of hiking as an event that exacerbated the Veteran's lumbar spine was a reference to the June 1997 in-service injury. As the October 2016 examiner did not provide any opinion specifically addressing direct service connection, the January 2020 VA examiner's reliance on this opinion demonstrates a misunderstanding of the October 2016 examiner's actual conclusion. The January 2020 VA examiner further noted that the October 1997 x-ray noted an indication of a 4-year history of trauma to the neck, and degenerative joint disease neck pain. The examiner noted that this x-ray was normal and would have been taken after the Veteran's hiking injury, but before the December 1997 VA examination. The Board again notes that the VA examination was conducted in October 1997 in conjunction with the x-ray. The examiner stated that the fact that the indication for the x-ray was neck pain and not lower back pain in addition to the normal findings did not support a conclusion that there was any significant back problem at that time. The examiner also stated that she was unable to find a single mention of any lumbar spine pain or other lumbar back problem in the records from 1995 to 1997, and there was no lumbar imaging in any of these notes. Despite what the examiner felt had been a thorough review of the record, the examiner could not find any reason to "overturn" the prior negative medical opinions. The evidence showed that the Veteran did not have any significant lumbar spine pathology until at least several years after his separation and that the various injuries that he suffered after separation were very likely the primary cause of his current lumbar conditions. In February 2021, A.C., RN, provided a positive medical opinion addressing the Veteran's theory of direct service connection. A.C. noted that the Veteran was found fit for military duty upon his enlistment with no report of any prior lumbar spine injuries or treatment. A.C. also acknowledged that the March 1997 separation examination was negative for any lumbar spine injuries or treatment. However, A.C observed that the relevant in-service low back injury occurred after this separation examination when the Veteran fell down a ravine in June 1997. A.C. noted that at that time, the Veteran complained of low back (tailbone) pain that was a 10 out of 10 with movement; and he exhibited no pain when not moving. The clinical impression was lower back strain, and the Veteran was prescribed Naprosyn (a non-steroidal anti-inflammatory drug) as well as Robaxin (a muscle relaxant) with instructions to apply heat to the area and modify duty for three days. A.C. noted that the Veteran reported low back pain after this injury during the post-service VA examination conducted approximately four months later in October 1997. Although the Veteran attributed his low back pain to his neck, A.C. noted that the low back pain manifested during service regardless of the causative factor. A.C. also opined that the Veteran in October 1997 had likely been trying to identify the causative agent for his low back condition from his lay perspective. A.C. also noted that although a lumbar spine x-ray performed at that time revealed normal findings, the Veteran's pain began during active duty; and pain cannot be identified on imaging studies. A.C. further stated that radiological findings should not necessarily be considered more important than clinical findings as the two findings did not always correlate or have a straightforward relationship. Pain may be present when x-ray or MRI findings are normal or only show minimal findings. A.C. also noted that a subsequent July 1999 treatment record documented a diagnosis of probable degenerative disc disease and acute low back pain in response to the Veteran's complaints of low back pain with radiation to both lower extremities after a water slide incident the previous day. The Veteran described his low back pain as identical to the pain that occurred after his fall down a ravine during military service in June 1997. The Veteran did not receive any imaging studies at that time, and his past medical history noted that he was discharged from the Navy with cervical and lumbar spine problem (emphasis added by A.C.). A lumbar spine x-ray that was later performed in October 2000 showed old-post traumatic compression changes at L1, possibly T12, and very mild probable post-traumatic compression fracture. A thoracic spine x-ray at that time confirmed an old compression fracture at T12. A.C. stated that it was unlikely that this post-traumatic compression fracture was the result of the Veteran's in-service low back injury as a lumbar spine x-ray in October 1997 was normal. The Veteran eventually required L5-S1 laminectomy and discectomy in November 2000. A November 2000 lumbar spine MRI revealed a large extrusion of disc material at L5-S1 that compressed the right S1 nerve roots and displaced bilateral S2 as well as all the more caudal nerve roots. A pathology report confirmed the presence of intervertebral disc degeneration at L5-S1. A.C. summarized that the Veteran continued to exhibit low back pain over the years for which he was followed by neurosurgery. A November 2004 treatment note reported that the Veteran continued to have low back pain that woke him up at night. A.C. noted that neither the January 2010 VA medical opinion nor the January 2020 VA medical opinion that addressed the Veteran's claim reflected consideration of the fact that the Veteran's low back pain had its onset during active duty service. In terms of the January 2020 VA medical opinion that the Veteran's low back disorder was the result of post-service waterslide and skiing injuries, A.C. disagreed. A.C. instead indicated that the Veteran post-service low back injuries were superimposed on his already present chronic low back pain. It was more likely than not that the post-service injuries aggravated the Veteran's low back pain that began during service after falling down a ravine. The record clearly demonstrated that the Veteran was treated for low back pain during active duty and continued to have low back pain post-service. The chronic nature of the Veteran's low back pain since his military service was evidenced by his continued complaints of low back from June 1997 until his waterslide injury and other post-service injuries. The low back pain had also persisted to the present time. A.C. explained that chronic low back pain was defined as pain that continued for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. A.C. observed that the Veteran's November 2020 Board hearing testimony reflected that he had "severe, severe low back pain" immediately following his in-service fall down a ravine. The Veteran also reported that he had symptoms of "gnawing low back pain" that was present even before the post-service waterslide incident. A.C. again noted that lumbar spine injuries are not always appreciated radiographically as x-rays cannot directly visualize discs and did not allow for visualization of soft tissue. Therefore, it was not possible to diagnose soft tissue damage by spinal x-ray alone. Spinal x-rays were typically preformed to confirm or exclude other possible causes of back pain such as tumors, infections, or fractures. Consequently, A.C. did not find it uncommon for the Veteran's October 1997 lumbar spine x-rays to reveal normal findings. A.C. stated that most lumbar spine pain is triggered by a combination of overuse, muscle strain, and injury to the muscles, ligaments, and discs that support the spine. Lumbar spine injuries can cause scar tissue to form which eventually weakens the back and increases the risk of more serious injury. A.C. also noted that lumbar spine degeneration was a slow and progressive condition that did not occur immediately following an injury. Therefore, the diagnosis of probable degenerative disc disease in July 1999 at the time of the post-service waterslide injury indicated that if degeneration of the lumbar spine was present in July 1999, the degenerative process would have needed to occur prior to the waterslide injury. The exact date of onset of the Veteran's lumbar spine degenerative disc disease was also unknown as the lumbar spine degenerative disc disease was not confirmed on imaging studies until November 2000. A.C. summarized that the Veteran's low back pain began during active duty, and he continued to suffer from lumbar spine pain that had been present since his military separation. The Veteran did not have a history of spine injuries or musculoskeletal problems prior to military service; and his STRs clearly demonstrated that his low back pain began while on active duty. As a result, A.C. stated that it was her professional opinion that the Veteran's chronic low back pain at least as likely as not first manifested while he was on active duty. A.C. also included citations to several medical articles in support of her conclusion. The Board finds that the February 2021 private medical opinion from A.C. provides great probative value as A.C. supported her opinion with a thorough rationale that included numerous references to the relevant evidence of record and reflected consideration of pertinent medical literature. A.C.'s opinion indicates that the Veteran's in-service lumbar spine injury made him more prone to the low back injuries that occurred after service, and the Veteran's current lumbar spine disorders are related to his in-service injury and chronic low back pain that began during active service. To the extent that A.C. partly relied on the Veteran's reported history of in-service lumbar spine symptoms that continued to be present after service, the Board notes that the Veteran is competent to report his history of observable symptoms such as low back pain. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible as his reports have been largely consistent throughout the appeal period. In addition, the Veteran provided an explanation for the limited in-service evidence of low back complaints as he indicated that he only sought treatment for his symptoms when they became very severe. Although the Board has considered the January 2010 and January 2020 VA examiners' negative medical opinions addressing direct service connection, the Board finds that they have minimal probative value. The January 2020 examiner appeared to rely on an incorrect interpretation of both the October 2016 VA medical opinion and the August 2018 Board remand instructions in providing an opinion. The examiner also misunderstood the timing of the post-service VA examination in October 1997, believing that it was not conducted until December 1997. Moreover, neither the January 2010 nor the January 2020 VA examiners addressed the potential significance of the Veteran's complaints of low back pain during the October 1997 VA examination despite the normal lumbar spine x-ray findings; or the July 1999 diagnosis indicating that probable degenerative disc disease was already present when he sought treatment for the waterslide injury after service. Based on the foregoing, the most probative evidence supports finding that entitlement to service connection for a lumbar spine disorder, diagnosed as lumbar degenerative disc disease and lumbar laminectomy and discectomy, is warranted. As the Board is granting service connection on this basis, it is unnecessary to address any other theory of entitlement advanced. The Board also notes that during the pendency of the current appeal period, the AOJ characterized the Veteran's service connection claim for a lumbar spine disorder as a service connection claim for chronic low back pain with sciatica. See, e.g., October 2009 Statement of the Case. As such, the Board finds that the current service connection claim for a low back disorder reasonably encompasses the right lower extremity radiculopathy that was diagnosed during the January 2020 VA examination. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the record has raised the theory that this disorder is secondary to the Veteran's lumbar spine disorder, the Board finds that it is appropriate to bifurcate the issues and adjudicate them separately. See Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011) ("[b]ifurcation of a claim is generally within the Secretary's discretion"); see also Tyrues v. Shinseki, 732 F.3d 1351 (Fed. Cir. 2013); Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions). In the January 2020 VA examination report, the examiner more specifically noted that the diagnosis of right lower extremity radiculopathy involved both the right femoral (L2/L3/L4) and right sciatic (L4/L5/S1/S2/S3) nerve roots. The Board finds that nature of the examiner's finding provides probative evidence that the Veteran's diagnosed right lower extremity radiculopathy was proximately due to, or the result of, his now service-connected lumbar spine disability as the examiner based the finding on clinical evidence and had an understanding of the Veteran's relevant medial history. There is also no negative evidence to weigh against this conclusion. As such, the Board finds that secondary service connection is warranted. See 38 C.F.R. § 3.310. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.