Citation Nr: 22011963 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 18-51 976 DATE: March 2, 2022 REMANDED Service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1978 to October 1998. This matter is on appeal from a May 2018 rating decision. The Veteran testified before the undersigned Veterans Law Judge at a November 2020 Board hearing. The Veteran contends that he developed a chronic back condition as a result of a back injury sustained in an in-service bicycle accident in Italy in 1982. He had been riding a 10-speed bicycle when he crashed, propelling him headfirst onto the asphalt. He has been experiencing back pain ever since. He testified that he sustained a traumatic brain injury and facial scars, along with a nose fracture. He recalled having 32 stitches in his head, spending 10 days in the Italian hospital. Additionally, his service duties required a lot of heavy lifting as he worked in the aerospace equipment and maintenance. See November 2020 Hearing Transcript. Service treatment records noted that on May 21, 1982, the Veteran was admitted to the Pordenone Hospital in Italy after a fall from a bicycle. He sustained superficial laceration of the head and abrasions to the face and shoulder. His general condition was satisfactory. An Authorization and Treatment Statement added that the Veteran sustained a concussion. There was no mention of any injury to his back. The next day on May 22, 1982, the Veteran was noted to be 'doing well, no complaints.' He had full recall of the accident and his condition was good. From May 24 to May 26, 1982, the Veteran continued to do well. His wounds were clean and healing. His stitches were removed on May 27, 1982. Discharge notes indicated that the Veteran sustained head trauma with concussion, multiple lacerative cutaneous wounds of the face and right ear, hematoma of the right auricular areas and a contusion of the thorax and right shoulder. It was silent for any injury to his back. His periodic examination in March 1985 noted no clinical abnormalities pertaining to his spine. During a June 1998 retirement physical, the Veteran noted his health was better than his last health assessment in June 1995 and his neck and extremities were clinically indicated to be normal. The Veteran's VA treatment records dating June 2009 revealed no tenderness on palpation to his low back. However, private treatment records dating August 2017 noted that the Veteran was diagnosed with other osteoarthritis of the lumbar spine, spondylolisthesis of the lumbosacral region, lumbar facet arthropathy, and degenerative scoliosis. In a March 2020 VA examination for traumatic brain injury, the examiner noted that the Veteran was involved in a 1982 bicycle accident in Italy and sustained multiple injuries. While service treatment records did not document a low back condition, the examiner concluded that an accident such as this would cause both a cervical extension injury as well as a lower thoracic flexion injury. In this case, the Board notes that the Veteran has presented with a current disability of a back condition and an in-service injury. However, a VA examination has not been obtained to address the etiology of the Veteran's back condition. Under the circumstances outlined above, the Board finds the low threshold required to obtain a VA examination had been met. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, a remand is required so that a medical opinion pertaining to the Veteran's back disability may be obtained. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by a clinician with sufficient expertise to diagnose and determine the nature and etiology of the Veteran's current low back disorder. The examiner is asked to address: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's current low back disorder had onset in service (to include his 1982 bicycle accident) or is otherwise related to service (to include heavy lifting of motors, generators and other aerospace equipment during 20 years of service)? Why or why not? In doing so, the examiner must consider the Veteran's service treatment records (which document his 1982 bicycle accident and injuries), the Veteran's Board hearing testimony, and the March 2020 Disability Benefits Questionnaire for TBI (finding that the Veteran's back injury is consistent with the 1982 accident). In responding to the above, the examiner is requested to specifically address the following: (b.) What types of back symptoms would have been caused by the in-service bike accident that resulted in a concussion with multiple abrasions to the face, shoulders and arms? (c.) What types of back symptoms would have been caused by Veteran's in-service heavy lifting of aerospace equipment? (d.) Is there any medical reason to accept or reject the proposition that the bike accident or in-service heavy lifting of aerospace equipment could have led to the current back disorder? Specifically, is there any medical reason to reject the March 2020 VA physiatrist's conclusion that the Veteran's in-service bike accident would cause both cervical extension injury as well as lower thoracic flexion injury? A complete and thorough rationale must be provided for any opinions expressed. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Yeh, Nicole 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.