Citation Nr: 21041680 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 12-20 538 DATE: July 9, 2021 REMANDED Service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1985 to May 1988. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision. In September 2018, a hearing was held before the undersigned; a transcript of the hearing is associated with the record. This case was previously before the Board in September 2018 and November 2020 when it was remanded for additional development. However, for the reasons discussed below another remand is required. See Stegall v. West, 11. Vet. App. 268 (1998). 1. Service connection for a low back disability is remanded. Despite the additional and regrettable delay, remand is required because there was not substantial compliance with the Board's November 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The November 2020 remand ordered a medical examination and opinion on whether the Veteran's low back disability might be related to his military service that included consideration of all pertinent evidence and competent lay reports. The examiner was directed to consider and address the 1995 post-service notations as documenting both a history of heavy lifting in service and a history of chronic low back pain with intervening work injuries post-service. A February 2021 VA addendum opinion was obtained on remand, but it does not appear to adequately consider and discuss the evidence. The opinion contains an inaccurate statement noting that the Veteran's current back symptoms did not manifest until 2013; however, there are records as early as 1995 that suggest a history of chronic low back pain. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 2. Forward the record to an orthopedist or other appropriate clinician for a clarifying medical opinion regarding the Veteran's low back disability. If a full in-person or telehealth examination (whichever is deemed more helpful) would be helpful (e.g., obtaining a more complete or detailed history of the onset, course, or progression of Veteran's low back complaints), one should be arranged. Based on a review of the full recordINCLUDING BUT NOT LIMITED TO the Veteran's own competent reports regarding the onset, course, and progression of his low back problemsand any findings on examination or clinical testing ordered to further probe this matter, the examiner should opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's low back disability is related to his military service or any injuries or events therein. 3. The examiner MUST SPECIFICALLY CONSIDER AND DISCUSS, as necessary, the significance of the Veteran's documented low back muscle spasm in 1986, and ALL competent lay reportsINCLUDING BUT NOT LIMITED TO his reports that his military work involved heavy lifting or that he also hurt his low back during a documented severe 1988 motor vehicle accident but was not treated for that injury because of his concurrent severe jaw fracture that was both relatively more severe AND left him unable to adequately report or complain about his back issues (given he could only open his mouth one inch at the time and the record shows he had residual speech difficulties even after treatment). The examiner MUST ALSO SPECIFICALLY CONSIDER AND DISCUSS the significance of the cumulative effect of the physical rigors of military service (based on both documented AND competently reported back issues therein) on his lumbosacral spine AS WELL AS post-service notations as early as 1995 that note BOTH a history of heavy lifting in service AND a history of chronic low back pain with intervening work injuries post-service. All opinions must include a complete rationale that complies with the Board's remand orders and sufficiently discusses ALL pertinent evidence (including but not limited to the evidence specifically noted above). [CONTINUED ON NEXT PAGE] Providing an opinion without a rationale my require further clarification and delay the resolution of this claim. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Braxton, 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.