Citation Nr: 21041664 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 20-01 548 DATE: July 9, 2021 REMANDED Entitlement to service connection for low back pain is remanded. Entitlement to service connection for left lower extremity radiculopathy of the sciatic, femoral, and external cutaneous nerves is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1964 to April 1970, July 1970 to April 1977, and April 1977 to June 1983. This matter comes before the Board of Veteran's Appeal (Board) on appeal from a September 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for low back pain is remanded. Here, although the Board regrets further delay, the Board finds that a remand is required. The Veteran has current lumbar spine conditions, including degenerative arthritis, spinal stenosis, and spondylolisthesis. See August 2018 VA Medical Report. August 2018 and November 2019 VA examiners found that the Veteran's current lumbar spine conditions are less likely than not related to the Veteran's in-service lumbar strain. See VA Medical Opinions dated August 2018 and November 2019. However, in addition to the lumbar strain diagnosis in service, the Veteran was also diagnosed with lumbar arachnoiditis, having a compressed disc, and inflammation due to Pantopaque reaction. See Service Treatment Records (STRs) dated September 1975, October 1975, and August 1978. Neither examiner addressed whether the Veteran's other in-service lumbar spine diagnoses were related to the Veteran's current lumbar spine conditions. In addition to these unaddressed in-service diagnoses, the examiners have also failed to address the Veteran's contention that he has experienced low back pain for many years. See Private Treatment Records dated September 1999 and February 2018. Therefore, the Board finds that these opinions are inadequate because the opinions do not consider all relevant evidence medical evidence and lay evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also notes that the Veteran provided an August 2019 positive nexus opinion that stated that the Veteran's current lumbar spine conditions were caused by the Veteran's in-service fall off a ladder. See August 2019 Private Medical Opinion. However, the Board finds that this opinion is inadequate for adjudicative purposes because the August 2019 treating physician failed to provide any rationale to support that finding. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). Moreover, the Board finds that the record raises the issue of whether the Veteran's service-connected cervical spine condition caused or aggravated the Veteran's lumbar spine conditions. Specifically, a September 1975 treating physician noted that following the Veteran's laminectomy to the cervical spine, the Veteran complained of acute pain radiating to the base of his spine. See September 1975 STR. The September 1975 treating physician also noted that the prior to this surgery, the Veteran's low back pain was in remission. Id. Therefore, the Board finds that an addendum opinion is necessary to address whether the Veteran's lumbar spine conditions are secondary to the Veteran's cervical spine condition. As the opinions obtained are inadequate, the Board finds that a VA addendum opinion is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The VA addendum opinion should comment on whether the Veteran's in-service diagnoses were early manifestations of the Veteran's current lumbar spine conditions. The examiner should also address the Veteran's contention that he has experienced low back pain since service. See Private Treatment Records dated September 1999 and February 2018. The examiner should also determine whether the Veteran's cervical spine condition caused or aggravated the Veteran's lumbar spine conditions. In ordering a remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran's lay reports. Rather, the Board is merely requesting that the examiner on remand consider the Veteran's own descriptions of the history of his lumbar spine conditions. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). 2. Entitlement to service connection for left lower extremity radiculopathy of the sciatic, femoral, and external cutaneous nerves is remanded. Although the Board apologizes for the delay, the Board finds that remand is necessary for further development. Here, the Veteran has been diagnosed with radiculopathy of sciatic, femoral, and external cutaneous nerve of the left thigh. See August 2018 VA Medical Opinion. The August 2018 VA examiner opined that the Veteran's radiculopathy of the sciatic, femoral, and external cutaneous nerves was related to the Veteran's lumbar spine conditions. However, the examiner failed to address whether the Veteran's radiculopathy had its clinical onset in service, seeing as the Veteran's STRs documented the Veteran's radicular pain. See STRs dated October 1977 and December 1978. Interestingly, the August 2018 VA examiner found that the Veteran's STRs were silent for radiculopathy, which contradicts the Veteran's STRs. Further, the November 2019 did not address whether the Veteran's radiculopathy was related to service. As the case currently stands, there is no adequate nexus opinion because the VA examiners failed to address whether the Veteran's in-service radicular pain were early manifestations of the Veteran's radiculopathy. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As the opinions obtained are inadequate, the Board finds that a VA addendum opinion is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The VA addendum opinion should comment on whether the Veteran's in-service complaints of radicular pain were early manifestations of the Veteran's radiculopathy of sciatic, femoral, and external cutaneous nerve. See STRs dated October 1977 and December 1978. In ordering a remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran's lay reports. Rather, the Board is merely requesting that the examiner on remand consider the Veteran's own descriptions of the history of his radiculopathy. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matters are REMANDED for the following action: 1. The RO should send the claims file to an appropriate VA examiner who has not previously participated in this case for an addendum opinion as to whether the Veteran's current lumbar spine conditions are related to service. The claims file, including a copy of this Remand, must be made available to and be reviewed by the examiner in conjunction with the examination. If a clinical evaluation is deemed necessary to answer the questions presented, one should be scheduled. A notation indicating that the claims file and remand was reviewed should be included in the examination report. Following review of the file and this remand, the examiner is to address the following: a. The examiner should determine whether it is at least as likely as not that the Veteran's current lumbar spine conditions, degenerative arthritis, spinal stenosis, and spondylolisthesis, had their clinical onset during service. For the purpose of providing the opinion requested, please accept as valid the Veteran's statements that he has experienced low back pain since service, and state whether a nexus between the Veteran's current lumbar spine conditions and service is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements). b. If you determine that the Veteran's current lumbar spine conditions did not have their clinical onset in service, then please state whether the Veteran's in-service diagnosis of lumbar arachnoiditis was an early manifestation of the Veteran's current lumbar spine conditions. See September 1975 STR. c. If you determine that the Veteran's current lumbar spine conditions did not have their clinical onset in service, then please state whether the Veteran's in-service diagnosis of a compressed disc was an early manifestation of the Veteran's current lumbar spine conditions. See August 1978 STR. d. If you determine that the Veteran's current lumbar spine conditions did not have their clinical onset in service, then please state whether the Veteran's in-service diagnosis of inflammation due to Pantopaque reaction was an early manifestation of the Veteran's current lumbar spine conditions. See October 1975 STR. f. Please state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's lumbar spine conditions were caused by the service-connected cervical spine disability. See September 1975 STR. g. Please state whether it is at least as likely as not that the Veteran's lumbar spine conditions were aggravated by his service-connected cervical disability. Here, aggravated means worsened beyond the natural progression of the condition. The examiner's opinion should reflect consideration of the Court's holding in Ward v. Wilkie that aggravation need not be permanent in nature. Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019); 38 C.F.R. § 3.310(b). h. If you find that the Veteran's lumbar spine conditions have been aggravated by the Veteran's cervical spine disability, please estimate the baseline severity of the Veteran's lumbar spine conditions before they were aggravated by his service-connected cervical spine disorder. i. The examiner should determine whether it is at least as likely as not that the Veteran's current radiculopathy had its onset during service. See STRs dated October 1977 and December 1978. For the purpose of providing the opinion requested, please accept as valid the medical evidence noting radicular pain in service, and state whether a nexus between the Veteran's current radiculopathy and service is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements). In offering any opinion, the examiner should consider medical and lay evidence dated both since the filing of the claim (May 2018). The examiner should provide a complete rationale for any opinion rendered. If the examiner's opinion is negative, he or she must clearly explain why. If he or she cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Foster, 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.