Citation Nr: 21042027 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 15-06 602 DATE: July 11, 2021 REMAND Entitlement to service connection for low back disability is remanded. REASONS FOR REMAND The Veteran had active service from April 1988 to November 1988 and from July 1989 to April 1992. He testified at a videoconference hearing before the undersigned in August 2017. This matter was before the Board in May 2018 and November 2019 when it was remanded for additional development. The Veteran contends that a back injury he sustained in 1987 resolved prior to his first period of active service (April 1988 to November 1988). He further contends that a fall from a truck during his second period of service (July 1989 to April 1992) resulted in an injury to his lower back that has caused him pain since that time. See August 2017 hearing transcript. Service treatment records (STRs) show that the Veteran reported a history of back pain since an April 1987 injury on an April 1988 Enlistment Report of Medical History. An April 1988 Enlistment Report of Medical Examination notes that orthopedic consultation showed 5-degree dorsal spine scoliosis; the Veteran had no pain and function of the lumbosacral spine was normal. An August 1989 STR notes the Veteran's complaints of coccyx pain after falling from a truck; the impression was soft tissue bone contusion. The Veteran was seen again in August 1990 with complaints of back pain that began while running; the diagnosis was myalgia. A March 1992 Separation Report of Medical Examination noted that clinical evaluation of the spine was normal. Post-service treatment records show the Veteran was seen as early as 1997 with complaints of low back pain; the diagnosis in June 1997 was low back spasm. Current diagnoses, as noted on a November 2019 VA Back Conditions Disability Benefits Questionnaire (DBQ), are scoliosis, bulging discs of the thoracic and lumbosacrum, and degenerative facet joint disease of the lumbar spine. The Board sincerely regrets any further delay in this matter; however, the December 2019 VA medical opinion obtained on remand is not adequate for adjudication purposes. The examiner found that scoliosis pre-existed the Veteran's service, and is a congenital/developmental defect. However, the examiner provided contradictory answers as to whether this defect was subject to a superimposed injury in service that resulted in additional back disability. Additionally, the examiner did not provide an etiology opinion for the Veteran's other diagnosed back disabilities (bulging discs of the thoracic and lumbosacrum with degenerative facet joint disease of the lumbar spine) See December 2019 Medical Opinion DBQ. For these reasons, remand for an additional opinion is needed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: Forward the Veteran's claims file to the December 2019 examiner for an addendum opinion. If this examiner is not available, forward the claims file to an appropriate VA examiner. The examiner must review the claims file (to include this remand) and provide addendum opinions as to whether it is at least as likely as not (a 50 percent or greater probability): (a) that the pre-existing congenital/developmental defect of scoliosis was subject to a superimposed injury or disease in service that resulted in additional back disability. In this regard, the examiner should address the evidence pertaining to the Veteran's pulled back muscle during his first period of active duty and back complaints following a fall from a truck during his second period of active duty. (b) that the current bulging discs of the thoracic and lumbosacrum with degenerative facet joint disease of the lumbar spine is of service onset or otherwise related to the Veteran's periods of military service, to include his pulled back muscle during his first period of active duty and back complaints following a fall from a truck during his second period of active duty. The examiner should also address the Veteran's August 2017 hearing testimony that he has experienced ongoing low back pain since service. (Continued on the next page) In offering any opinion, the examiner must consider the full record, to include the lay statements (including the Veteran's statements and hearing testimony) and medical reports of record. A clear rationale for any opinion offered should be provided. Where possible, reasoned medical explanations connecting conclusions with supporting data are specifically requested. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Fletcher, Kathleen 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.