Citation Nr: 23014346 Decision Date: 03/09/23 Archive Date: 03/09/23 DOCKET NO. 17-62 708A DATE: March 9, 2023 ORDER Service connection for a back disability is granted. Service connection for right lower extremity neuropathy is granted. Service connection for left lower extremity neuropathy is granted. FINDINGS OF FACT 1. The Veteran's lumbosacral spine strain and degenerative disc disease, status post lumbar laminectomy, had its onset in service. 2. The Veteran's right lower extremity neuropathy had its onset in service. 3. The Veteran's left lower extremity neuropathy had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.102, 3.303. 2. The criteria for service connection for right lower extremity neuropathy have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.102, 3.303. 3. The criteria for service connection for left lower extremity neuropathy have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1966 to December 1969. The Veteran died in March 2018 and the Appellant is the Veteran's surviving spouse. The Appellant is the Veteran's surviving spouse and she has been recognized as the valid substitute for the pending appeal. See April 2020 Department of Veterans Affairs (VA) notification letter. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection requires evidence of a current disability, an in-service incurrence, disease or injury and a causal relationship between the current disability and the in-service incurrence, disease or injury. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for a back disability 2. Service connection for right lower extremity neuropathy 3. Service connection for left lower extremity neuropathy The Veteran asserted in a June 2017 affidavit that his back disability and bilateral lower extremity neuropathy are related to or had their onset in service, citing his in-service incidents and duties as a helicopter mechanic and injuring his lower back during a physical training exercise. The Veteran stated that his back pain worsened as a result of the physical training incident and the lifting of heavy objects on a regular basis while on serving on active duty aggravated his back pain, impacting his legs as the pain radiated downward and he need to seek treatment go to Sick Call. The Veteran noted that in 1968 his back symptoms were treated by a physician, and he was ordered to limited duty profile due to his injury. He added that he tolerated the pain in his back and legs for the duration of his service and treatment only provided limited relief; he recalled being issues a back brace after separation from service in 1969. The Veteran also stated that his back pain and lower extremity pain has continued since service, deteriorating over the years causing functional loss and the inability to complete daily living activities at times. The Veteran's service treatment records document a history of lumbar spine pain and lower extremity neuropathy complaints. A September 1967 record stated the Veteran complained of lumbar spine pain that started three months prior when Veteran lifted a heavy object, and further exacerbated by performing PT; Veteran was diagnosed with a back strain and provided medication. Veteran complained of low back pain radiating into the legs when running in October 1967; an X-ray demonstrated slight scoliosis of the lumbar spine. The Veteran sought treatment at a physical therapy clinic for his low back in October 1967. In March 1968, the Veteran against presented complaints of low back pain with radiation into the right leg. Another March 1968 treatment note showed evaluation for trauma to the lumbosacral area with persistent right sided back pain and right groin pain. In July 1968, the Veteran sought emergency treatment for "back trouble for over a year and a half;" he was again diagnosed with low back strain. August 1968 STRs showed Veteran was placed on limited duty secondary to scoliosis with right sided sciatic pain and he was ordered not to handle heavy materials, including weapons. STRs from January 1969 further showed Veteran complained of back pain with scoliosis and the provider stated there was suspected "degenerative joint disease secondary to scoliosis." The Veteran's separation examination from November 1969 stated the Veteran exhibited "mild right scoliosis," and that the Veteran suffered a back injury in 1967 and "has had recurrent back problems." Post-separation, the Veteran submitted a consultation letter from a private physician in November 1983 in which the physician stated the Veteran had undergone a lumbar laminectomy in July 1983, and in August 1983 the Veteran continued to experience back pain with right leg pain. VA treatment notes from July 2006 also noted Veteran complained of lower back pain with radiating pain to the front of the thighs; the Veteran's medication was increased, and he was referred for a pain management consultation. Further post-service treatment records note the Veteran underwent a second lumbar surgical procedure in 2005, and he continued to use pain medication to alleviate the pain in his lumbar spine. The Veteran underwent a VA back examination in April 2012, in which he was diagnosed with lumbar degenerative disc disease, spinal stenosis, and intervertebral disc syndrome (IVDS). The Veteran also exhibited mild intermittent pain in the bilateral lower extremities, with moderate numbness in the bilateral lower extremities; he was diagnosed with mild radiculopathy in the bilateral lower extremities. The VA examiner opined that the review of the records failed to find a specific injury or etiology of back pain while in service expect the pain associated with scoliosis, which can cause wear and tear on the disc and vertebrae of the spine, leading to arthritis to form later in adulthood. In April 2016, the Veteran complained of worsening back pain over the years and lower back fatigue with episodes of "pinpricking burning pain in the mid-anterior thigh and lower on the posterior thigh." The Veteran was afforded another VA back examination in May 2016; he was diagnosed with degenerative arthritis of the spine. The Veteran reported he was forced to walk with the assistance of a walker, his leg and back symptoms are relieved for 3-4 months by injection and his pain is worsened by walking and moving. The VA examiner opined negatively regarding the etiology of the Veteran's back and leg pain and stated the Veteran's leg symptoms appear to be diabetic neuropathy and not radiculopathy. Further, the examiner opined that Veteran's spine condition was due to aging. In a private medical opinion received by the Board in September 2017, a private physician rendered a medical opinion regarding the etiology of Veteran's lumbar spine and bilateral lower extremity disabilities. The physician opined that it was at least as likely as not that Veteran's lumbar spine disability was related to his in-service injuries, as the complaints and symptoms have been well documented and consistent dating back to September 1967. The physician did not attribute the back complaints to the scoliosis diagnosis; rather, he attributed the complaints to the injuries and arthritic condition present in the lumbar spine as a result of Veteran's active duty service. The physician also opined that it is at least as likely as not that Veteran's bilateral lower extremity neuropathy is due to the lumbar spine disability, as multiple radiology studies of the spine demonstrated extensive lumbar disc disease, spinal canal stenosis, foraminal narrowing, and degenerative disc disease. The Board observes that the Veteran was competent to report having back pain and lower extremity neuropathy symptoms in and since service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's lay statements, which have been corroborated by other lay evidence, to be both competent and credible. The Board acknowledges the service treatment records that note complaints and treatment of back pain and radiating pain into the lower extremities, the April 2012 and May 2016 VA examinations for the back and the VA examiners' negative nexus opinions in April 2012 and May 2016. The Board considers the Veteran's June 2017 Affidavit and lay statements therein, in which he notes his documented medical history of recurrent back and lower extremity symptomatology along with the history of surgical intervention and narcotic medication in attempts to mitigate the back and lower extremity pain. The Board also acknowledges the September 2017 positive private medical opinion submitted by a private physician after a review of the entire medical record. As a finder of fact, the Board finds the Veteran's reports of having back and bilateral lower extremity problems since service both competent and credible. Further, he was diagnosed as having degenerative arthritis, lumbar disc disease, and canal stenosis of the spine and bilateral lower extremity neuropathy. In light of the foregoing, and resolving doubt in the Veteran's favor, the Board finds service connection is warranted because the Veteran's back disability and bilateral lower extremity neuropathy had its onset in service, and he showed that he continued to have recurrent back and bilateral lower extremity symptoms while continuously seeking treatment for his disabilities post-service. See 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zarar Ahmed, Attorney Advisor 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.