Citation Nr: 22013426 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 18-11 883 DATE: March 9, 2022 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to June 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision. The Board notes that the Veteran's appeal also originally included the issues of entitlement to service connection for a bilateral leg disorder, a left knee disorder, and bilateral heel bone spurs. However, following the issuance of a statement of the case (SOC) in January 2018, the Veteran limited his February 2018 substantive appeal to the issue identified above and did not include these other issues. Accordingly, they are not currently on appeal to the Board. In July 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. The Veteran was afforded a VA examination in May 2016 in connection with his claim. The examiner noted that he had back complaints 40 years earlier with no evidence of any leg symptoms and that he separated from service without any complaints other than one-time spasms. He also observed that the Veteran did not have symptoms for 10 years after service. Therefore, the examiner opined that the Veteran's back disorder is not at least as likely as not related to service. An additional VA medical opinion was obtained in October 2017. The examiner concluded that the Veteran's back disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She noted that the Veteran had complaints in service and that x-rays were not obtained at that time to determine if he had a pars defect, which would have predisposed him to later development of spondylolisthesis. However, she also observed that he had reported having normal x-rays in the 1980s, which would mean that he had a muscular strain in service. She further commented that the fact that leg symptoms were not documented in service meant that imaging was not clinically warranted at that time. In contrast, the Veteran later had surgery in the 1990s for the diagnosis of anterolisthesis (anterior spondylolisthesis) of the lumbar spine, which is an entirely different diagnosis and attributable to inappropriate movement of the L4 on L5 junction due to a pars defect. The examiner explained that a musculoskeletal strain in service would not be a cause of the later development of bony/disc degenerative disease. During the July 2020 hearing, the Veteran's representative contended that VA medical opinions were based on an incomplete history of the Veteran's back problems and incomplete medical evidence. The Board does note that the October 2017 VA examiner indicated that the private treatment records were incomplete. Specifically, she stated that the actual clinical notes from the Veteran's private care providers had not been associated with the record. Moreover, an April 2018 statement from a private physician, Dr. M.K. (initials used to protect privacy), indicates that he reviewed the x-rays from the 1980s and that they show grade I anterolisthesis L4 on L5. Such a finding contradicts the factual premise of the October 2017 VA examiner's medical opinion. Therefore, the Board finds that an additional VA medical opinion based is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his low back. A specific request should be made for any outstanding private treatment records from Kaiser Permanente and x-ray reports from the 1980s (appear available in light of Dr. M.K.'s April 2018 statement indicating that he had reviewed them). After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After the above development has been completed, the Veteran should be afforded a VA examination to determine the etiology of his current low back disorder. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran's low back disorder is causally or etiologically related to his military service, to include any injury or symptomatology therein. In rendering this opinion, the examiner should consider the service treatment records documenting complaints of back problems with a positive straight leg raise test noted in July 1975. He or she should also consider an April 2018 statement from Dr. M.K. in which he indicated that he had reviewed x-rays from the 1980s and that they show grade I anterolisthesis L4 on L5. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should review the examination report to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.