Citation Nr: 21032417 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 06-27 076 DATE: May 27, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND In an October 2019 decision, the Board denied the Veteran's claim for entitlement to service connection for a low back disability. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which in a September 2020 Order and pursuant to a Joint Motion for Remand (JMR), vacated the October 2019 denial and remanded the case to the Board. In November 2017, the Board remanded the matter for further development, pursuant to the terms of the JMR. The matter has now returned to the Board for consideration. 1. Entitlement to service connection for a low back disability is remanded. In the parties JMR, they agree that the Board erred in relying on a June 2019 VA negative nexus opinion. The parties agreed that the opinion was insufficient in only one respect, namely that the June 2019 VA examiner failed to resolve "how [the Veteran's] 1974 in service back injury was a 'superficial soft tissue injury' in light of [the Veteran's] 30-day hospitalization in service." Accordingly, the Board will remand the matter for an opinion to address this question. See 38 C.F.R. § 4.2; see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion or ordering a medical examination). The matters are REMANDED for the following action: 1. Return the claims file to the examiner that conducted the June 2019 VA examination, if available, for an addendum opinion to assess the nature and etiology of the currently assessed low back disability. Make the claims file available to the examiner for review of the case. If the June 2019 VA examiner is not available, the claims file must be available to another appropriate health care provider for the requested opinion. The claims folder and a copy of this remand must be made available to the examiner. The examiner should note in the examination report that the claims folder has been reviewed. The examiner is asked to address whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low disability had its clinical onset during active service or is related to the March 1974 low back injury documented in the service treatment records. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In terms of rationale, the examiner must specifically address how the Veteran's March 1974 back injury has been described only as a "superficial soft tissue injury," that was acute and self-limiting considering his reported 30-day hospitalization for the injury. In other words, the examiner is asked to address the likelihood that the 30-day hospitalization indicates that the injury was not superficial, acute and self-limiting in formulating his or her opinion. In providing this opinion, the examiner should consider and address the following: 1) The Veteran injured his low back during physical training in March 1974 and was assessed as having an acute low back strain; 2) He developed a grapefruit sized hematoma in the lumbar area the day following the March 1974 injury; 3) He was hospitalized for 30 days due to the injury, but the records of this hospitalization are unavailable; 4) A July 1974 X-ray examination of the lumbar spine showed no abnormalities; and 5) VA examinations have characterized the injury as superficial, acute and self-limiting. C. TRUEBA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Joseph R. Keselyak, 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.