Citation Nr: 22016603 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 11-18 528A DATE: March 22, 2022 REMANDED Entitlement to service connection for a low back condition is remanded. REASONS FOR REMAND The Veteran had active service from January 1963 to January 1966, and from November 1967 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this issue in October 2015, March 2017, November 2017, August 2020, and October 2021. While the Board regrets the additional delay, the matter must be remanded again. The Veteran seeks entitlement to service connection for a low back condition, which he contends is secondary to his service-connected prostate cancer. Specifically, he contends that the prostate cancer caused or aggravated his low back condition, as he first experienced low back pain shortly after he underwent radioactive seed implantation procedure to treat his prostate cancer. Alternatively, the Veteran contends that his low back condition is due to his posttraumatic stress disorder (PTSD) The October 2021 Board remand requested an opinion that addressed the July 2021 medical literature submitted by the Veteran and that adequately addressed whether the Veteran's PTSD or prostate cancer had aggravated his low back condition. An addendum opinion was provided in December 2021. The examiner concluded that the Veteran's prostate cancer had no relationship with his low back pain. However, the examiner did not provide an adequate opinion as to aggravation, concluding that "the two conditions are unrelated, therefore aggravation is not plausible." As the examiner did not provide an opinion with supporting data and rationale, the opinion is inadequate as to aggravation. The examiner did not address the Mayo Clinic literature submitted by the Veteran that suggested that some types of arthritis and cancer can contribute to back pain. The examiner provided a similar opinion as to whether the Veteran's low back condition was aggravated by his service-connected PTSD, concluding that the conditions were not medically related and therefore aggravation was not possible. The examiner noted that depression and anxiety can present as back pain, but that here the Veteran had radiographic evidence of a lumbar spine condition. Again, the examiner did not adequately explain if the Veteran's low back pain is worsened by his service-connected PTSD. A medical opinion as to secondary service connection must address both causation and aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). As the opinions provided do not address the aggravation prong of secondary service connection and have not complied with the Board's prior remand instructions, remand for an addendum opinion is necessary. Stegall v. West, 11 Vet. App. 268, 271 (1988). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back condition has been aggravated (i.e. worsened) beyond its normal progression by the Veteran's service-connected prostate cancer or PTSD, including as due to any treatment for either condition. The examiner must specifically address the medical articles and submissions the Veteran has provided to support his contentions, and which suggest back symptoms (pain) can be influenced by cancer or psychiatric issues. The examiner should address whether in the Veteran's case, his back pain (although inherently arising from his degenerative arthritis of the spine) has a component that is associated with either his prostate cancer or his PTSD, and in that sense is aggravated by those service connected disabilities. If there is such an additional component to his pain, the extent of that should be quantified, if possible. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as "any increase in disability." See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The examiner must provide a complete rationale for all opinions and conclusions reached. If the examiner feels that any requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 2. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Geer, 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.