Citation Nr: 22008051 Decision Date: 02/11/22 Archive Date: 02/11/22 DOCKET NO. 14-05 325 DATE: February 11, 2022 ORDER Service connection for a low back disability is granted. FINDING OF FACT The competent and probative evidence is in approximate balance as to whether the Veteran's lower back condition had its onset in or is otherwise related to his period of active service. CONCLUSION OF LAW The criteria for service connection for a lower back condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1976 to December 1976 and from December 1990 to May 1991, with additional service with the Army National Guard and Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was most recently before the Board in August 2021, at which time it was remanded for further development, as discussed below. As the requested development has been substantially completed, no further action to ensure compliance with the remand directives is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection for a low back disability. The Veteran contends that his low back disability had its onset during active service. Alternatively, the Veteran contends that his low back disability is proximately due to or aggravated by his service-connected right ankle disability. The Veteran has had a current diagnosis of degenerative disc disease of the lumbar spine during the relevant appeals period, as shown at the VA examination in February 2012. 02/02/2012, VA Examination. And, the Veteran has been diagnosed with degenerative changes of the lumbar spine with mild anterior subluxation of L4 with respect to L5, as shown in a January 2020 VA examination and associated x-ray imaging report. 01/31/2020, C&P Exam; 01/31/2020, C&P Exam (imaging report). Thus, a present disability has been established by competent and credible evidence. An August 2021 Board decision remanded the claim of service connection for a low back disability and directed the Agency of Original Jurisdiction (AOJ) to obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of any low back disability. The Board found the prior VA medical opinions to be inadequate, as the VA examiners did not sufficiently address relevant evidence, to include an April 1991 medical history report, an October 1998 service medical certificate, and the Veteran's statements that he has had problems with his lower back since service. 08/27/2021, BVA Decision. An October 2021 VA examination found that the Veteran's back condition had improved and did not have pathology to render a current diagnosis. Nonetheless, the examiner acknowledged that the Veteran currently experiences back pain and had prior diagnoses of lower back conditions. The examiner opined that the Veteran's current back pain more likely than not originated during his active service. Specifically, the examiner indicated that the service treatment records show an incurrence of a back condition during active service and the medical records further show there is a continuity of care for this condition. 10/20/2021, C&P Exam; 10/20/2021, C&P Exam (medical opinion). The Board finds that the evidence is at least in approximate balance regarding whether the current low back condition is related to the Veteran's active service. The Board places probative weight on the October 2021 VA examination because the pertinent medical history was considered, particularly the relevant service treatment records and the Veteran's credible statements regarding the onset of his low back pain. Therefore, the Board finds that service connection for a low back disability is warranted. 38 C.F.R. § 3.303. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David Han 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.