Citation Nr: 21031109 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 14-30 554 DATE: May 20, 2021 REMANDED Entitlement to service connection for a thoracolumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1974 to September 1986 and April 1990 to March 1994. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). A January 2021 Court of Appeals for Veterans Claims (Court) Order granted a Joint Motion for Partial Remand (JMPR) to vacate the portion of the Board's June 2019 decision denying service connection for a thoracolumbar spine disability and a cervical spine disability. The Court determined that the Board failed to satisfy its duty to assist when it did not make reasonable efforts to obtain relevant service department records and also found that the Board relied in part on an inadequate VA examination and opinion in forming its reasons and bases for denying service connection for a cervical spine disability. A March 2021 Board decision remanded the claims of entitlement to an initial compensable rating for bilateral hearing loss and service connection for a disorder manifested by episodic dizziness for further development. 1. Entitlement to service connection for a thoracolumbar spine disability is remanded. 2. Entitlement to service connection for a cervical spine disability is remanded. In this case, 2013 progress notes from Keesler Air Force base pertaining to the Veteran's neck and back were adequately identified when he sought treatment in May 2013 at Singing River Health System and stated that he had been receiving physical therapy at Keesler and had brought his treatment notes from this therapy with him to his May 2013 appointment at Singing River Health System. The 2013 physical therapy notes from Keesler were adequately identified and constitute relevant federal records because the records relate to the disabilities on appeal. Accordingly, remand is warranted to attempt to obtain the 2013 physical therapy notes from Keesler Air Force Base. See § 5103A(c)(1)(C). Further, in a November 2011 VA cervical spine examination, the examiner opined that it was less likely than not that the Veteran's cervical spine disability was incurred in or caused by an in-service injury. However, the examiner focused his rationale on whether the Veteran's neck disability was etiologically related to an in-service fracture in 1980. See June and July 1980 entries in the service treatment records (STRs) documenting a fracture of the spinous process of C7. He failed to address the likelihood that the Veteran's current cervical spine disability was related to an in-service neck injury that occurred in January 1993. In this regard, the STRs contain a January 1993 entry noting that the Veteran presented complaining of neck pain and was assessed with torticollis and prescribed limited duty. Accordingly, the Board finds that remand is required to obtain an opinion as to whether it is at least as likely as not that the Veteran's currently diagnosed cervical spine disability is etiologically related to service, including the in-service notation in January 1993 where the Veteran complained of neck pain and was assessed with torticollis. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain an opinion, it must ensure that the examination or opinion is adequate.) These matters are REMANDED for the following actions: 1. Obtain updated VA treatment records. (Continued on the next page) 2. Obtain physical therapy records from Keesler Air Force Base dated in 2013 related to the Veteran's back disabilities. The RO must make as many requests as necessary to obtain the relevant records, until a determination has been made that the records sought do not exist or that further efforts to obtain those records would be futile. See § 5103A(c)(1)(C); 38 C.F.R. § 3.159(c)(2). 3. After the above records have been associated, schedule the Veteran for an examination with an appropriate provider to determine the nature and etiology of his currently diagnosed cervical spine disability. Following a complete review of the evidence of record, and with consideration of the Veteran's lay statements, assuming the statements are credible for the limited purpose of the request herein, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability is etiologically related to service, including the January 1993 entry in the STRs which reflects a complaint of neck pain and assesses the Veteran with torticollis and prescribes him limited duty. The examiner should also consider the June 1980 in-service fracture of the spinous process of C7 and the Veteran's statement that he fell off ladders several times while on active duty. See March 2013 entry from Singing River Health System. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alison M. Mecone, 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.