Citation Nr: 22051210 Decision Date: 09/08/22 Archive Date: 09/08/22 DOCKET NO. 19-19 681 DATE: September 8, 2022 REMANDED Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to service-connected lumbar spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1989 to August 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In part, the Veteran filed claims seeking service connection for a back disability and bilateral lower extremity radiculopathy. The RO granted service connection for a lumbar spine disability and associated right lower extremity radiculopathy in a June 2019 rating decision. As the full benefits sought on appeal for the lumbar spine disability and right lower extremity service connection claims have been granted, the claims are no longer before the Board. In January 2022, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript is of record. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to service-connected lumbar spine disability While the Board regrets the delay, a remand is needed for additional development. This is necessary to ensure that the Veteran is afforded every possible consideration and that there is a complete record upon which to decide his appeal. In the June 2017 rating decision on appeal, the RO denied service connection for left lower extremity radiculopathy for lack of a current clinical diagnosis. The Veteran was afforded VA back examinations in April 2016 and May 2017, in connection with which left lower extremity radiculopathy was not found. The Veteran submitted a private May 2019 back disability benefits questionnaire which shows the private examiner did not find left or right lower extremity radiculopathy. During the January 2022 Board hearing, the Veteran's representative contended that a private March 2019 nexus opinion from Dr. K.R. shows that Dr. K.R. referenced nerve pain and numbness in the Veteran's "legs," which indicates the presence of both right and left lower extremity radiculopathy. The Board notes, however, that Dr. K.R. also references "leg pain" in the March 2019 opinion, which conflicts with the later reference to "legs" in the same opinion. The Veteran submitted a March 2022 nexus opinion from Dr. K.R. However, Dr. K.R.'s March 2022 opinion addresses only the Veteran's lumbar spine disability, and does not address left lower extremity radiculopathy. During the January 2022 Board hearing, the Veteran testified that he noticed left lower extremity radicular symptoms of pain, numbness, difficulty walking, and his leg locking up when he first separated from active duty service. March 2022 "buddy" statements from three daughters all stated that they first noticed the Veteran had bilateral leg trouble around 2003, when the Veteran's legs were tingly and did not respond, and he needed assistance getting up. A review of the record shows complaints of sharp radiating pain down the Veteran's left leg in a March 2016 VA treatment record. The Board finds that additional information is necessary to adjudicate this issue. There is no medical opinion of record which directly addresses left lower extremity radiculopathy, including the March 2016 complaint of back pain radiating to his left leg, his daughters' statements, and his reports of left lower leg radicular symptom onset soon after separation from active duty. The Board therefore finds that a remand is warranted to obtain a VA examination to assess the nature and etiology of the Veteran's claimed left lower extremity radiculopathy disability. Finally, the Board notes that the record indicates there may be relevant, outstanding private medical treatment records. The Veteran's VA treatment records indicate he received private treatment for his lumbar spine disability and/or lower extremity radiculopathy from Dr. A in Cabot, Arkansas, Dr. C.J., and a chiropractor. See March 2016 and June 2017 VA Treatment Records. Additionally, during the January 2022 Board hearing, the Veteran indicated he received treatment from a doctor in Branson, Missouri, a civilian scholarship program clinic in Springfield, Missouri, and Dr. E. at Baptist Internal medicine. On remand, the RO should attempt to obtain any relevant, outstanding treatment records identified by the Veteran. The matter is REMANDED for the following action: 1. Ask the Veteran to identify relevant private treatment records not already of record, including Dr. Abram in Cabot, Arkansas, Dr. Crystal Johnson, private chiropractor(s), a private doctor in Branson, Missouri, a civilian scholarship program clinic in Springfield, Missouri, and Dr. Ezell at Baptist Internal Medicine. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records. The Veteran should also be notified that he may submit evidence or treatment records to support his claim. 2. Schedule the Veteran for examination by an appropriate clinician to determine the nature and etiology of his left lower leg radiculopathy disability. The examiner must review the entire claims file, to include a copy of this Remand, in conjunction with authoring the opinions, and such review should be noted in the examination report. The examiner is asked to address the following: (a.) Whether the Veteran has a current diagnosis of left lower extremity radiculopathy. (b.) If the Veteran does not have a current diagnosis of left lower extremity radiculopathy, the examiner is asked to reconcile the March 2016 VA treatment record showing complaints of back pain radiating into his left leg, and the Veteran's January 2022 Board hearing testimony. (c.) If the Veteran has a current diagnosis of left lower extremity radiculopathy, the examiner is asked to address the following: (1) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left lower leg radiculopathy had its onset during military service, was caused by, or is otherwise related to, the Veteran's military service. (2) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left lower leg radiculopathy is proximately due to his service-connected lumbar spine disability, or (3) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left lower leg radiculopathy was aggravated by his service-connected lumbar spine disability. The term "aggravation" means a worsening of a disability beyond its natural progression, regardless of permanence. If aggravation is found, then, to the extent possible, the examiner should establish a baseline level of disability prior to such aggravation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the examiner cannot provide an opinion without resorting to speculation, he or she must provide complete explanations stating why this is so. In so doing, the examiner must explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted (Continued on the next page) the limits of current medical knowledge in providing an answer to that particular question(s). C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Battaile 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.