Citation Nr: 21031380 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 14-37 451 DATE: May 21, 2021 ORDER Entitlement to service connection for a low back disability is denied. FINDING OF FACT The Veteran's low back disability was not caused or aggravated by service-connected peripheral neuropathy (PN) of the lower extremities (LE). CONCLUSION OF LAW The criteria for service connection for a low back disability are not met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1968 to October 1970. This appeal comes to the Board of Veterans' Appeals (Board) from a July 2010 rating decision of the Department of Veterans' Affairs (VA) regional office (RO). The appeal has a lengthy procedural history and was most recently remanded by the Board in November 2020. Service connection for a low back condition claimed as secondary to service-connected PN The Veteran contends that his current low back disability was caused or aggravated by his service-connected PN of the LE. See, e.g., October 2010 Notice of Disagreement (NOD). Because the Veteran has not raised, and the record does not reasonably raise, entitlement to service connection on any other theory, the Board's adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Initially, the Board finds the Veteran does have a current diagnosis of a low back disability; specifically, severe spinal stenosis and degenerative disc disease. See January 2021 VA Examination. Thus, the first element of secondary service connection is satisfied. Next, service connection for PN of the LE is in effect beginning September 30, 2005. Thus, the second element of secondary service connection is likewise satisfied. The remaining question before the Board is whether the Veteran's current low back disability is proximately due to or the result of, or was aggravated beyond its natural progression by, PN of the LE. The nexus evidence presented in favor of the Veteran's claim consists of the Veteran's lay statements and his treating physician's statement. In June 2012, VA physician Dr. C.C. wrote a letter stating that she had treated the Veteran for 10 years and "[t]he pain in his back has increased likely due to his impaired gait." Dr. C.C. did not specifically attribute the impaired gait to PN, nor was a rationale provided to support this statement. In the absence of a rationale, this is not an adequate medical opinion to support service connection. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board assigns no probative weight to Dr. C.C.'s statement. The Veteran has submitted several statements explaining why he believes that his low back disability is caused or aggravated by his service-connected PN. In his September 2014 VA Form 9, he wrote that his service-connected PN in his LE "put a lot of pressure on my lower back[, w]hich damage[d] my disc the L4-L5, spondylolisthesis with lumbar stenosis to include the left lumbar radiculopathy, which makes it hard to stand and walk and balance myself without severe pain." Similarly, in his NOD he wrote that "PN nerve damage in my feet and legs has made my lower back distressing and damaging. The back condition...was brought on by losing the strength to [balance] myself with my feet and legs, which is still a problem brought on by PN." The Board does not doubt the Veteran's sincere belief in this theory of service connection. However, the issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, he is not competent to provide a medical opinion linking the low back disorder to his PN. The Board assigns no probative weight to the Veteran's lay statements regarding causation and aggravation. VA examination and/or opinions were obtained in July 2014, November 2018, September 2020, and January 2021. All opinions found it was less likely than not that the Veteran's low back disability was secondary to his service-connected PN. The appeal has been remanded numerous times in order to obtain an adequate VA opinion addressing the aggravation theory. As explained below, the Board finds that the January 2021 VA opinions are adequate and substantially comply with the prior remands. Prior to January 2021, none of the opinions provided an adequate rationale regarding the theory of aggravation. See February 2020 Joint Motion for Remand; May 2020 and November 2020 Board remands. In addition to requiring a separate rationale for aggravation, the 2020 Board remands also directed that the examiner address the 2012 statement by Dr. C.C. and the Veteran's reports of back pain increasing with neuropathy. The January 2021 examiner substantially complied with all directives. She opined that the baseline level of severity of the back disability was established by MRIs showing severe spinal stenosis in 2004 and 2009, and that the current severity of the back disability was greater than that baseline. However, the back disability was less likely than not aggravated beyond its natural progression by the service-connected PN. The examiner's rationale addressed both the 2012 statement by Dr. C.C. and the Veteran's lay reports: While right LE PN/muscle atrophy itself does not aggravate spinal stenosis/DJD of the spine, the 2012 provider opined that his worsening of his back condition may have been secondary to his altered gait. Documentation in the c[laims] file does not support this relationship. In June of 2009, the Veteran was evaluated for possible surgery of the lumbar spine. His MRI at that time showed progression at the L4/L5 level but examination by neurosurgeon revealed he was able to perform regular, heel/toe/tandem gait testing, without evidence on exam of altered gait or cane used for ambulation. It is less likely than not that his PN aggravated his back condition, as over a period of five years, his back condition progressed/worsened irrespective of an altered gait. While the Veteran reported back pain increased with the Neuropathy, it would be difficult for the Veteran to tell if the pain was actually worse from the Neuropathy or due to progression of the spinal condition. The Board finds this opinion probative, as it provided a clear conclusion with supporting data, and reasoned medical explanations connecting the two. Stefl, 21 Vet. App. at 124-25; Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As the only probative and adequate aggravation opinion is against the claim, service connection must be denied on an aggravation basis. As for the theory that the back disability was caused by the PN, the Board finds that the probative evidence is against the Veteran's claim. The July 2014 examiner stated that although the Veteran has clearly documented PN of the LE, it is far more likely than not that his lower back pain is due to L4-5 spondylolisthesis with marked lumbar spine canal stenosis. However, this opinion failed to address whether the stenosis and spondylolisthesis themselves were caused by the PN. Therefore, it is not adequate. The July 2018 examiner opined the back disability is less likely than not due to or the result of PN and explained: "The peer reviewed medical literature does not support PN causally related to his low back conditions." The September 2020 examiner echoed this opinion but provided additional rationale: "Peripheral neuropathy does not cause or result in DJD/spinal stenosis of the spine. Review of current medical literature does not support this relationship. In addition, altered gait does not result in spinal stenosis/DJD of the lumbar spine as again, review of current medical literature does not support this relationship." The examiner went on to list the causes of spinal stenosis, citing to medical literature: overgrowth of bone, herniated disks, thickened ligaments, tumors, and spinal injuries. Finally, in the January 2021 addendum opinion, the September 2020 VA examiner provided additional rationale: "The Veteran was [diagnosed] with severe spinal stenosis in 2004. In 2005, he was seen by a Neurologist for his LE Neuropathy and it was documented at that time that Veteran's stance was normal, gait normal, and tandem gait normal on examination. While PN/muscle atrophy, is not a cause of severe spinal stenosis, there is question of the spine condition being secondary to altered gait from PN. The Veteran did not have evidence of altered gait at diagnosis of back condition. In addition, documentation shows no evidence of an altered gait, one year after spinal stenosis diagnosis." The examiner went on to list three specific treatment records documenting normal or unremarkable gait. The Board finds that the VA examination reports, taken together, are probative on the question of secondary causation, as they collectively provide a clear conclusion with supporting data, and reasoned medical explanations connecting the two. Stefl; Nieves-Rodriguez. The Board has thoroughly reviewed the record but finds no probative evidence which establishes a causal relationship between the Veteran's lower back disability and his service-connected PN. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As such, entitlement to service connection for a low back disability is denied. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Brewer, 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.