Citation Nr: 21031341 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-54 441 DATE: May 21, 2021 REMANDED Entitlement to service connection for a thoracolumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1988 to December 1991. This matter comes before the Board of Veterans' Appeals (Board) from a December 2012 rating decision. The Veteran testified at a Board hearing in June 2019. The Board remanded this matter in June 2020. *** The Veteran asserts that he has a thoracolumbar spine disability that is related to an injury in service or secondary to his service-connected neck disability. He further asserts that his back and neck disabilities are due to the same injury in service. Radiology reports from July 2010 (submitted with the Veteran's request to reopen) shows that the Veteran had very minimal spondylosis to the left at T7/8 and T8/9 (deemed normal for age) and early degenerative desiccation at L3/4 and L4/5. 10/06/2011, Medical Treatment Record -Non-Government Facility. A February 2012 VA treatment note shows that he had left thoracic pain and shows a diagnosis of mild degenerative disk disease and facet arthrosis at L3/L4 and L4/L5, which results in mild bilateral neural foraminal narrowing. 02/27/2020, CAPRI, at 311. A March 2021 VA examination shows diagnoses of degenerative disc disease, status post partial discectomy T7-8, and lumbar radiculopathy of the left lower extremity. Regarding onset of symptoms, the examiner noted that the condition began in 1994 with pain in the left side of the thoracic spine. The March 2021 VA examiner opined that the Veteran's back disability is less likely than not related to service or secondary to a service-connected disability. Regarding direct service connection, the examiner's rationale was there was no objective evidence of a back condition during service and that a back condition was first noted in a July 2010 MRI, approximately 19 years after the in-service MVA. Regarding secondary service connection, the examiner's rationale was that spondylosis of the cervical spine is not a known cause or risk factor for degenerative desiccation of the lumbar spine. The examiner further explained that disc desiccation is typically caused by wear and tear on the spine with age. The March 2021 VA opinion is inadequate for the following reasons. First, the opinion does not show adequate consideration of the relevant evidence. Specifically, the opinion failed to consider the Veteran's report of back pain since 1994. Additionally, while the opinion references the in-service MVA, it fails to acknowledge that the Veteran has reported a second in-service incident where he injured his thoracic spine. This injury, which occurred because of lifting a heavy (58 lb.) object, is described in an August 2004 statement, which also provides insight into the nature of the in-service MVA. 08/11/2004, Correspondence. Secondly, the opinion lacks a comprehensive medical rationale, as it relies overwhelmingly on the absence of corroborating evidence of symptoms or treatment to rule out a nexus. Finally, the examiner did not provide a rationale for the opinion regarding the aggravation prong of secondary service connection. For these reasons, another remand is necessary to obtain a new VA opinion. This matter is REMANDED for the following action: Obtain an addendum medical opinion from an appropriate clinician regarding the Veteran's claim of service connection thoracolumbar disability. The clinician is asked to provide a response to the following: (a.) Is the Veteran's thoracolumbar disability at least as likely as not related to an injury in service? **In providing this opinion, consider the Veteran's description of his in-service injuries and symptoms as well as his post-service symptoms. For a detailed description of the Veteran's two reported in-service injuries, see the August 2004 statement from the Veteran. 08/11/2004, Correspondence. Also consider the Veteran's report of thoracolumbar pain since 1994.** If there is any medical reason to accept or reject the proposition that the Veteran's reported injuries 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? (b.) Is the Veteran's thoracolumbar disability at least as likely as not proximately due to his service-connected cervical spine disability? (c.) Alternatively, is it at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected cervical spine disability? (d.) Finally, is it at least as likely as not that any current arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a comprehensive medical rationale to support all opinions. Please avoid rationales that are solely based on the absence of corroborating evidence of symptoms or treatment, either in service or after service. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.