Citation Nr: 21042611 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-05 859A DATE: July 13, 2021 REMANDED Service connection for left leg radiculopathy as secondary to service-connected lumbosacral strain is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1970 to October 1976. This matter comes before the Board of Veterans' Appeals (Board) from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Service connection for left leg radiculopathy as secondary to service-connected lumbosacral strain is remanded. The Board remanded this matter for development in June 2020. Unfortunately, remand is required for further development. The RO last adjudicated the appeal in a November 2020 supplemental statement of the case (SSOC). Thereafter, additional relevant treatment records were added to the record. The Veteran has not waived RO initial review of this evidence; thus, the Board must remand the appeal. 38 C.F.R. §§ 19.37(b), 20.1304(c). In compliance with the Board's June 2020 remand directives, a VA peripheral nerves examination was provided in October 2020. While the October 2020 VA examiner indicated the Veteran did not have a peripheral nerve condition or peripheral neuropathy, a subsequent November 2020 VA treatment record notes pain with palpation to the L3/L4 and L4/L5 spinous process and left paraspinals and electrical type burning pain to left foot resulting from palpation of the sciatic notch. Based on the Veteran's complaints, a VA clinician ordered further tests to include a lumbar MRI and neurosurgery evaluation. VA records show the lumbar magnetic resonance imaging (MRI) was performed in December 2020. The clinical results included findings of spondylotic degenerative changes with mild to moderate spinal canal narrowing at L2/L3, L3/L4, and L4/L5 with no foraminal stenosis. An electromyogram (EMG) was conducted in December 2020. While a VA treatment record indicated the electromyogram (EMG) results were unremarkable, the physician who conducted the EMG requested a further neurosurgery consultation for low back pain with left lower extremity radicular symptoms. VA treatment records indicate the Veteran was referred to a non-VA facility/provider for the neurosurgery consultation and pain management in January 2021. The neurosurgery consultation was conducted by Dr. Kelkhar and pain management was also by a non-VA physician, Dr. Upadhyay in January 2021; unfortunately, these records are not in the claims file for the Board's review. Although the VA treatment note indicates that the private records were scanned in VISTA, they are not located in the claims file. Rather, the evidence of record only reflects a referral by Dr. Kelkhar to Dr. Upadhyay. Accordingly, a remand is required to allow the RO to make the records available for the Board's review, and/or if necessary, obtain authorization to request these records from those non-VA providers. Finally, as the October 2020 VA examination did not include any diagnostic studies prior to determining that a left lower extremity radiculopathy is not present, an addendum opinion that reflects consideration of the subsequent diagnostic studies (i.e. lumbar spine MRI, EMG and the neurosurgery consultation) should be obtained on remand. The matter is REMANDED for the following action: 1. Take appropriate steps to obtain the relevant medical records from the non-VA neurosurgery evaluation and pain management by Drs. Kelkhar and Upadhyay for the Board's review. If necessary, ask the Veteran to complete a VA Form 21-4142 for these non-VA clinicians and/or medical facilities (to include the Pain Management Optum CCP and Southfield Michigan Spine and Brain Surgeons). Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. After any additional records are located and associated with the claims file, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has a current diagnosis of left leg (lower extremity) radiculopathy. If the examiner finds a current diagnosis of radiculopathy, the examiner should opine whether the Veteran's radiculopathy is at least as likely as not (1) proximately due to his service-connected lumbar spine disability or (2) aggravated beyond its natural progression by his service-connected lumbar spine disability. In formation of the opinion, the examiner must review the entire claims file, including VA treatment records subsequent to the October 2020 VA peripheral neuropathy examination report, to include the December 2020 EMG and lumbar spine MRI results, and any relevant records obtained from the Veteran's neurosurgery consultation and/or pain management referral. The examiner must provide a rationale for all proffered opinions. If the requested opinion cannot be provided without resorting to speculation, the examiner should provide an explanation as to why speculation is required. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, 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.