Citation Nr: 22015802 Decision Date: 03/19/22 Archive Date: 03/19/22 DOCKET NO. 16-46 362 DATE: March 19, 2022 REMANDED Service connection for lumbar spine ruptured disc with stenosis and degenerative arthritis is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1979 to September 1982 with additional Reserve service. This matter comes before the Board of Veterans' Appeals (Board) from December 2012 and February 2014 rating decisions rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2016, the Veteran testified before a Decision Review Officer (DRO). In October 2019, the Veteran testified before the undersigned Veterans Law Judge at a travel Board hearing. Transcripts are of record. The Board remanded this matter in January 2020 for further development. In December 2020, the Board denied this matter. The Veteran appealed the December 2020 Board decision to the United States Court of Appeals for Veterans Claims (the Court). In November 2021, the Court granted a Joint Motion for Remand (JMR) vacating and remanding the December 2020 Board decision for adjudication consistent with the JMR. Service connection for lumbar spine ruptured disc with stenosis and degenerative arthritis is remanded. In December 2020, the Board denied service connection for the claimed lumbar spine disability. The November 2021 JMR acknowledged that a new VA medical opinion was obtained in February 2020; however, the opinion did not mention the lay statements from J.S., the Veteran's sister or from former servicemembers, C.C. and K.K. as required by the January 2020 Board remand. The Board must remand for an addendum opinion to address the concerns stated in the JMR . See Stegall v. West, 11 Vet. App. 268 (1998). The Board reiterates that the Veteran contends he injured his back in December 1980 during a work detail involving unloading camouflage nets from a truck. See, e.g., July 2011 VA Form 4138. The Veteran reports his back symptoms began in December 1980 and have continued, intermittently, since service discharge. For clarity, the March 2013 buddy statements received from the Veteran's former fellow servicemen, C.C. and K.K., reflect their personal knowledge of the Veteran having injured his back in 1980. These statements do not, however, reflect their personal knowledge of continuity of back pain or similar symptoms since discharge from active duty in 1982 to the present. Likewise, a January 2014 statement from J.S., one of the Veteran's sisters, indicates that she personally observed the Veteran complain of back pain, and take medication for such, from 1982 until 1985 and since 1989. This statement does not reflect her personal knowledge of the Veteran having had continuity of back pain or similar symptoms since discharge from active duty in 1982 to the present. In contrast, statements dated in January 2014 from E.M., another one of the Veteran's sisters and R.B., the Veteran's brother, appear to corroborate the Veteran's current assertion of having recurrent back pain intermittently since discharge from service. E.M. indicated back pain has been an ongoing problem for the Veteran throughout the years and that the pain became so unbearable after service that he had to have back surgery. R.B. indicated that the Veteran returned home with a back injury that worsened over time leading to surgery. The Veteran's post-service treatment records indicate treatment for back pain and related symptoms since July 1988. A February 1989 private treatment record shows the Veteran underwent a lumbar spine operation in February 1989. May 2004 correspondence from the Veteran's private treatment provider indicates that in July 1988, the Veteran reported repetitively lifting about 50-to-60-pound objects when he felt a pulling in his lower back with radiation into the buttocks. An August 2008 treatment record indicates the Veteran reported the pain is intermittent and that his current episode of pain started 20 years ago while lifting heavy equipment at work. A July 2015 treatment record indicates the Veteran reported his current episode of pain began in December 1980. The November 2021 JMR further indicated that the opinion also did not mention the two favorable nexus opinions from January 2017 and April 2017. In January 2017, Dr. J. W. also opined that the Veteran's current back problems are related to injuries in service. This opinion was, in part, on the Veteran's self-reported history of having 'ruptured a disc in his lower back' in December 1980. The Board notes that while the service treatment records are limited, they do not reflect any evidence of the Veteran having ruptured a disc in his lower back during active duty. In April 2017, the Veteran's private physician, D.P., opined that the Veteran's back problems are related to his previous injuries while in the Army. A rationale was not provided for this opinion. An addendum opinion that considers the Veteran's assertion of recurrent back pain since service discharge and the favorable private opinions is needed. The matter is REMANDED for the following action: Obtain an addendum opinion regarding the nature and etiology of the Veteran's current lumbar spine disability. a) The examiner must opine whether a current back disability is at least as likely as not related to an in-service injury, event, or disease, including the Veteran's reports of a back injury in December 1980. b) The examiner must opine whether lumbar spine arthritis at least as likely as not (1) began during active service or (2) manifested within one year after discharge from active duty. The examiner should review the Board's instant remand, and consider the favorable private nexus opinions and lay reports of recurrent back symptoms since service as discussed in the January 2014 lay statements from E.M. and R.B., the Veteran's siblings. In providing the rationale, the examiner must consider the Veteran's description of his in-service injury and symptoms; the January 2014 lay statements from E.M. and R.B. regarding of post-service back symptoms; and the Veteran's general assertions of having recurrent back symptoms since discharge. If there is any medical reason to accept or reject the proposition that the Veteran's reported in-service injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. (Continued on the next page) Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed lumbar spine disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 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.