Citation Nr: 21039965 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-51 682 DATE: July 1, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1983 through October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In November 2018, the Board remanded the appeal for further development, to include a supplemental opinion. Entitlement to service connection for a low back injury is remanded. The Veteran asserts that his current low back disability had its onset in service. It is well documented that the Veteran incurred a mechanical back injury in 1984 while on active duty. However, the Veteran was involved in a post-service motor vehicle accident (MVA) in 2014 which resulted in increased back pain. In April 2014, the Veteran received diagnoses of multiple back disabilities, to include multilevel disc degeneration, sciatica, erosive arthritis, and spinal stenosis. See 2014 treatment notes of Dr. D.M. It was also noted that the Veteran suffered from a traumatic back injury in service. Dr. D.M. stopped short of issuing a favorable nexus opinion; he merely stated that "not all diagnoses pertaining to [the Veteran's] back pain could have been caused by the MVA. Id. The Veteran was afforded a VA examination in June 2015. The VA examiner, Dr. D.J.K., authored a negative nexus opinion, which included the following statement: A separation examination from 1987 that documented [sic] recurrent low back pain consistent with a lumbar muscle strain. The Veteran reports that after his active duty, he was able to pursue over 20 years of work in the automotive, welding, and construction industries that all have significant demands . . . Furthermore, the majority of treatment he has received for his current complaint has been since 2002 when he sustained a disc-related back injury nearly 15 years after active duty. Dr. D.J.K. failed to discuss the significance of the different diagnoses and lay statements suggesting symptoms endured regularly since service. Therefore, the Board must dismiss the findings of Dr. D.J.K., the June 2015 examiner, as inadequate. By May 2016, the Veteran was diagnosed with disc degeneration, lumbar spinal stenosis with neurogenic claudication, spinal stenosis, erosive arthritis with associated stenosis at L4-L5, spondylolisthesis, and neural foraminal stenosis, and radiculopathy. See surgical report of Dr. T.M.S. In May 2016, the Veteran underwent back fusion surgery, to include a minimally invasive lumbar laminectomy. See Consultation Notes from T.W. and Dr. T.M.S. His private care surgeon noted that the Veteran's back disability symptoms began in the military. See January 2016 consultation notes of T.W. and T.M.S. Subsequently, the Veteran submitted a September 2016 private opinion letter, in which Dr. D.M. noted that the Veteran had sustained traumatic back injury in the military in 1984. Dr. D.M. noted the Veteran's involvement in a 2014 MVA resulted in neck and back pain. In November 2019, the Veteran underwent a VA back examination. The VA examiner, Dr. D.J.S., concluded that the question of aggravation by a post-service MVA was moot. Dr D.J.S. explained that the Veteran's "current back condition was less likely as not due to injury in service." The November 2019 VA examiner explained that medical literature did not support musculo-ligamentous strain as a cause of degenerative arthritis. The Board finds that the November 2019 opinion of Dr. D.J.S., much like the 2015 opinion of Dr. D.JK., failed to adequately address the other aspects of continuity of symptomatology, to include lay statements by the Veteran. Both VA opinions also failed to address the evolution of the Veteran's symptoms over time. Dr. D.J.K. and Dr. D.J.S., were conclusory in their opinions to the extent that they relied on alternative causes for the Veteran's symptoms without offering adequate explanation to associate specific symptoms with the pain that the Veteran has experienced since service. In other words, the topic of continuity was not fully explored. In a May 2020 written statement, the Veteran detailed continuity of symptomatology since the in-service onset of his back pain. There is no reason to determine that the Veteran's statements are fraudulent or lack authenticity. While the Veteran is competent to report symptoms he experienced firsthand, a determination as to whether any current disabilities are related to his in-service muscle strain is a complex matter requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). Here, there is no suggestion on the record that the Veteran has the specialized training or experience necessary to offer a competent opinion on such a matter. Unfortunately, there are statements to support a service connection claim, but there are more statements to suggest that the Veteran's claimed back condition is due to his job responsibilities, an MVA, and degradation of the spinal column over the course of many years. The Board thus determines that a remand is warranted to obtain an expert medical opinion addressing the nature and etiology of the Veteran's claimed back injury. The matter is REMANDED for the following action: 1. Arrange to have the Veteran scheduled for a VA examination to determine the nature and etiology of any lumbar spine disabilities. If possible, the examiner should be someone other than Dr. D.J.S. or Dr. D.J.K. The examiner must review the claims file and should note that review in the report. The examiner should obtain a complete history from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. The examiner must address the June 2015 and November 2019 VA examination reports. Additionally, the examiner must address the Veteran's statements about continuous back pain since his 1984 in-service injury. All findings should be reported in detail. The examiner should first diagnose all lumbar spine disabilities found. Then, the examiner should opine as to whether it is at least as likely as not (i.e., is it 50 percent or more probable) that any lumbar spine disorder was caused by or is related to service. The examiner should specifically address the Veteran's in-service injury in 1984, the private treatment records of Dr. D.M. and Dr. T.M.S., both of whom indicate in-service onset of back pain. The examiner should also make sure to address the Veteran's lay statements regarding complaints of back pain since the time of his in-service injury. By a May 2020 written statement, the Veteran explained that his back disability has followed him throughout his life. After being "treated numerous times for back injuries" throughout his service in the US Army. A complete rationale for all opinions expressed must be provided and reconciled with statements made by the Veteran and his primary care physicians. It should not include speculation based on the Veteran's work responsibilities. 2. Then, readjudicate the claim remaining on appeal. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Roya Bahrami Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Lanton, 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.