Citation Nr: 22045167 Decision Date: 08/09/22 Archive Date: 08/09/22 DOCKET NO. 19-35 873A DATE: August 9, 2022 REMANDED Entitlement to an increased initial rating for a service-connected spine disability is remanded. Entitlement to service connection for sciatica, left lower extremity, is remanded. Entitlement to service connection for sciatica, right lower extremity, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from January 1978 to January 1981, from April 1984 to May 1987, and from February 1991 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision. In December 2020, the Veteran testified before the undersigned Veterans Law Judge at a hearing. The Veteran's mother was also present for the hearing. A transcript of the hearing is of record. While delay is regrettable, the Board finds remand is necessary before an informed decision can be made. 1. Entitlement to an increased initial rating for a service-connected spine disability is remanded. 2. Entitlement to service connection for sciatica, left lower extremity is remanded. 3. Entitlement to service connection for sciatica, right lower extremity, is remanded. The Veteran contends that his service-connected spine disability warrants an increased initial disability rating. During his December 2020 hearing, he testified that he has experienced times when his back has stiffened to the point of incapacitation, and that he has incapacitating episodes daily, in the morning, that last for 30 to 45 minutes. He testified that he uses a back brace and a cane; that he has gone to Johns Hopkins for two years for treatment; that he has been told he needs surgery; and that he has been prescribed bed rest by VA doctors. The Veteran also testified that he experiences numbness, shooting pain, burning, and tingling in his bilateral legs. See December 2020 hearing transcript. In connection with his February 2018 claim for service connection, the Veteran was afforded a VA examination to assess the nature and severity of his back disability in April 2018, and addendum opinions were provided in July 2018 and September 2018; as a result, service connection was granted with an evaluation of 40 percent effective the date of the Veteran's claim. However, subsequent evidence, including the Veteran's December 2020 hearing testimony as discussed above, suggest that his disability may have worsened. Additionally, although no medical examination has identified the presence of sciatica in ether the left or right lower extremity, the Veteran contends that he has sciatic symptoms in his bilateral legs that are related to his active service and/or proximately due to or aggravated by his service-connected spine disability. As the Board is remanding this appeal in part so that the Veteran may be scheduled for an updated VA examination, and at that examination neurological impairment will be assessed, the Board will defer adjudication of the issue of service connection for sciatica in the bilateral lower extremities pending the results of the examination ordered on remand. In light of the discussion above, the Board finds that a more contemporaneous examination is needed to fully and fairly evaluate the issues on appeal. See Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). While this case is in remand status, all outstanding VA treatment records must be obtained and associated with the evidence of record; additionally, any pertinent outstanding private treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the record. 2. Give the Veteran an additional opportunity to identify and/or submit any outstanding pertinent evidence, including private treatment records, that have not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. Schedule the Veteran for an examination to evaluate the severity of his back disability. The claims file, including all electronic records, must be made available to the examiner. Any indicated diagnostic tests and studies must be accomplished. The examiner should take a history from the Veteran as to the progression of his claimed disability. All pertinent symptomatology and findings should be reported in detail. a) All indicated tests and studies should be performed, including range of motion findings expressed in degrees and in relation to normal range of motion. b) The examination must include testing results for pain on both active and passive motion, and in weight-bearing and nonweight-bearing. The examiner should assess where pain begins on the Veteran's initial range of motion and upon repetitive testing. Further, the examiner should describe any pain, weakened movement, excess fatigability, and incoordination present. c) The examiner must estimate any functional loss in terms of additional degrees of limited motion experienced during flare-ups and repetitive use over time. If the examiner cannot provide the above-requested opinion without resorting to speculation, he or she should state whether all procurable medical evidence has been considered, to specifically include the Veteran's description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner's medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). d) In particular, upon examination of the spine, the examiner should identify and assess the severity of all associated neurological abnormalities, to specifically include bilateral lower extremity sciatica, if present. The examiner must provide a rationale for all opinions requested. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, readjudicate the Veteran's claims based on the entirety of the evidence. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.