BVA9502234 DOCKET NO. 93-09 515 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a sinus condition. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Martin F. Dunne, Counsel INTRODUCTION The veteran served on active duty from June 1956 until July 1990. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA), St. Petersburg, Florida, Regional Office (RO). REMAND Essentially, the veteran contends that his back and sinus conditions were first manifest while he was on active duty service. He claims that he injured his back in a lifting incident in 1979 and has had periodic back problems ever since including incapacitating incidents occurring anywhere from two to four times a year. He claims that he developed sinus problems in approximately 1960 and has had periodic problems ever since. He also notes that he was treated for perennial allergic rhinitis while on active duty. At his physical examination at the time of his retirement form active duty, he claims that he complained of back and sinus problems and, at the physical examination, he asserts that he was prescribed medication for back pain by the examining physician. The Board notes that the veteran's service medical records are incomplete, that they only cover limited periods of time between 1979 until 1990, and that these records do not include a complete copy of his retirement physical examination. Indeed, the few pages from the veteran’s service medical record which are available were supplied by the veteran himself. Accordingly, further development is required. The veteran also expressed his dissatisfaction with the VA examination administered in April 1991. He claims that the examiner did not take into account consideration the veteran's complaints of pain on motion of his back, nor did the examiner describe the range of motion found upon examination except in the vaguest of terms. The Board notes, however, that the veteran’s lumbar range of motion was specifically described as "full." Still, it is well to observe that disc space narrowing was observed on x-ray study of the lumbosacral spine, and that the examiner did not comment on this finding. Hence, additional development is required. Accordingly, pursuant to the VA's duty to assist the veteran in development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), this case is REMANDED for the following action: 1. The RO should make one additional attempt to secure the veteran’s complete service medical record. In this respect, the RO should contact the National Personnel Records Center in St. Louis, Missouri, as well as the Naval Reserve Personnel Center in New Orleans, Louisiana, and request that they provide any and all service medical records which they may have in their possession. Furthermore, the RO should contact the veteran and request that he return to the custody of the United States any and all original service medical records which he may have in his possession. Should the veteran desire to keep a copy of any original medical records he currently holds, the RO shall provide him with appropriate assistance consistent with the provisions of the Privacy and Freedom of Information Acts. The RO should document any and all attempts to secure the veteran’s complete service medical record, and followup on any and all leads to their logical conclusion. 2. Copies of any VA, private and/or service facility medical records created subsequent to July 1990, are to be obtained and incorporated with his claims file. 3. Following the completion of the foregoing, and the incorporation of any records received into the claims file, the RO should schedule the veteran for orthopedic, neurologic and otolaryngological examinations at a VA medical facility. These examinations must be conducted in accordance with the VA Physician’s Guide for Disability Evaluation Examinations. All appropriate tests are to conducted including radiological studies. The veteran's claims file, together with a copy of this remand, must be provided to and reviewed by all examiners prior to their respective studies. The examiners are to report detailed findings, both positive and negative, as well as a complete rationale for all opinions expressed. Moreover, the orthopedic and neurologic examiners are requested to note any limitation of lumbosacral motion demonstrated and to offer an opinion whether such limitation is due to pain. Additionally, the orthopedic and neurological examiners are requested to offer an opinion as to whether the veteran suffers from a congenital defect of the spine. If a congenital defect is diagnosed the examiners must provide an explanation as to how such a conclusion was reached, what medical text was relied upon in determining the disability to be a "congenital defect," and whether or not the veteran now manifests a superimposed lumbosacral disability. (E.g. Lumbosacral arthritis manifested by intervertebral disc space narrowing.) 4. When the above-mentioned action is completed, the RO is to review the veteran's claim. If any part of the examination report is not in full compliance with this remand, it should be returned to the VA medical facility for appropriate action. If the decision remains unfavorable to the veteran, he and his representative are to be provided with a supplemental statement of the case and afforded the appropriate period of time in which to respond. Thereafter, in accordance with current appellate procedures, the claims file, to include the requested additional evidence, is to be returned to the Board for further appellate consideration. No action is required on the part of the veteran until he is further notified. DEREK R. BROWN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).