Citation Nr: 21031227 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 14-25 384A DATE: May 20, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1975 to July 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019 the Board denied the Veteran's claim of entitlement to service connection for a low back disability and service connection for TBI. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In August 2020 the Court issued a memorandum decision that set aside the Board's decision, with remand for readjudication. 1. Entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for TBI is remanded. Pursuant to the August 2020 memorandum decision issued by CAVC, a remand is needed to fulfill VA's duty to assist. The Veteran asserts that he fell in service and injured his back and suffered a possible brain injury at the same time. His service treatment records reflect that he fell and injured his back in 1977, and again in September of 1978. The Veteran was treated for low back pain syndrome in June 1979 and was hospitalized for 8 days. In the Veteran's March 1979 separation examination, a notation included in the record specifically directs the reader to "[s]ee summary from USPHH [United States Public Health Hospital] in New Orleans [January 19, 1979], as to [back] strain." A June 1979 service treatment record (STR) mentions that the Veteran "was sent to the United States Public Health Hospital in New Orleans in January 1979," for 9 days, during which he underwent "an extensive medical and orthopedic work up." Also, the same June 1979 STR reports that the Veteran was "again referred from the out-patient clinic in Miami to the Baltimore Public Health Service Hospital (BPHSH) for further work up and evaluation especially to rule out conversive hysterical personality and organic brain syndrome." The January 1979 treatment record from USPHH is not contained in the claims file and should be obtained. While the narrative summary of the Veteran's June 1979 treatment is in the file, a complete record of the Veteran's hospitalization during this period is necessary to further assess his claim. It is unknown whether the Veteran received treatment at the BPHSH, to the extent that he did, these records are also not in the claims file but are relevant to his appeal and should be obtained. In the Veteran's October 2012 statement in support of claim, he indicates that he is "currently on SSI from social security because of my back pain which disables me." In February 2015 a physical residual functional capacity questionnaire from the Social Security Administration (SSA) was associated with the Veteran's claims file. Thus, it appears the Veteran has outstanding SSA records which should be obtained since they may be relevant to his back disorder. As there are currently outstanding records that need to be associated with the claims file, the Board finds that a new VA examination with opinion and rationale is needed for the Veteran's back disorder, diagnosed as degenerative arthritis of the spine and spinal stenosis. Regarding the Veteran's claim for TBI, when the Secretary undertakes to provide a veteran with a VA medical examination or opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). While the June 2014 VA TBI examiner stated that he reviewed the claims file and the Computerized Patient Record System, he only noted that Veteran suffered a head injury at work in 2011, and did not specifically discuss the Veteran's 1977 or September 1978 in-service falls that are asserted to have resulted in a possible brain injury. Finally, the Veteran reported in his October 2012 statement in support of claim that he gets headaches and forgets his appointments. In his July 2014 VA Form 9 the Veteran reiterated that he has had headaches since that in-service incident. VA treatment notes from April 2011 to June 2012 reflect that the Veteran has been treated for, among other things, anxiety, depression, and sleep difficulties. Because the examiner failed to account for relevant details of the Veteran's medical history as noted above, the Court found that the June 2014 VA TBI examination report is inadequate. On remand, the examiner will need to address whether any of the symptoms the Veteran reportedly experienced after his fall were manifestations of a TBI, or whether they were related to some other health issue. The matters are REMANDED for the following action: 1. Obtain any additional service treatment records. This includes the January 19, 1979 and June 1979 treatment from United States Public Health Hospital in New Orleans, and any treatment records from Baltimore Public Health Service Hospital. Document all requests for information as well as all responses in the claims file. 2. Obtain the Veteran's federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 3. Once the above development is complete, schedule the Veteran for a VA examination for his low back disorder. The examiner must review the claims file and should review the Board's remand. The examiner is asked to provide a response to the following: a) Is the Veteran's low back disorder at least as likely as not related to service, including his in-service falls? b) Is it at least as likely as not that the Veteran's degenerative arthritis of the spine (i) began during active service, (ii) manifested within one-year after discharge from service, or (iii) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinions provided for a) and b). 3. Schedule the Veteran for a VA TBI examination. The examiner must review the claims file and should review the Board's remand. a) The examiner is asked to address whether the Veteran suffered a TBI in-service, or whether he experienced any TBI manifestations that are still present. b) If the Veteran suffered a TBI in-service, or experienced any TBI manifestations at the time, which are still present, then is the current TBI or TBI manifestations at least as likely as not related to service, specifically to include his in-service falls? Provide a rationale to support the opinion. In providing the requested opinion and rationale, consider the Veteran's description of his in-service injury and symptoms as well as his reported post-service symptoms which includes headaches, memory loss, depression, and sleep difficulties. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. 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? D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.