BVA9502847 DOCKET NO. 90-01 970 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for degenerative arthritis of the lumbosacral spine with referred hip pain. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Hilary L. Goodman, Counsel INTRODUCTION The veteran had active service from April 1942 to October 1945. The Board of Veterans' Appeals (Board), in a decision issued on March 25, 1991, denied the veteran's claim for service connection for degenerative arthritis of the lumbosacral spine with referred hip pain. This decision was appealed to the Court of Veterans Appeals (Court). By memorandum decision dated September 22, 1992, the Court vacated the Board's decision and remanded for the Board to further develop the record and reexamine the evidence. The Board in February 1993, following review, remanded the case to the originating agency for development of the evidence and readjudication of the issue. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that during service he injured his back in judo training when he was thrown and landed on his low back. He asserts that this was followed by swelling and a pilonidal cyst and that, after surgery for the pilonidal cyst, gangrene developed and he underwent multiple additional surgeries for the cyst, further aggravating his low back. He further asserts that, while the first medical record of arthritis of the low back is dated in 1977, he was given pain medication for his arthritis of the low back by the Department of Veterans Affairs (VA) pharmacy for many years previous to this. He finally contends that, as he has been examined by orthopedic specialists and they have concluded that his degenerative arthritis of the lumbosacral spine with referred hip pain is due to his low back injury in service and the repeated surgical treatment he received for the pilonidal cyst, service connection should be granted for this disability. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran's claim for service connection for degenerative arthritis of the lumbosacral spine with referred hip pain. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim has been obtained by the originating agency. 2. A chronic disorder of the lumbosacral spine was not present in service. 3. Degenerative changes of the lumbosacral spine were first manifested over 3 decades post service and are not shown to be related to any incident of service. CONCLUSION OF LAW Degenerative arthritis of the lumbosacral spine with referred hip pain was not incurred in or aggravated by active service, and service incurrence of this condition may not be presumed.. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993) REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran is seeking service connection for degenerative arthritis of the lumbosacral spine with referred hip pain. After reviewing the record, the Board finds that his claim is plausible; therefore, it is well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board is also satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The service medical records reflect that on examination of the veteran in April 1942 for entry into service, there were noted to be no musculoskeletal defects. Service clinical records show that he was seen for a pilonidal sinus with mild drainage in August 1942. It was noted that the skin about the sinus was mildly macerated from exudate. He was admitted to the hospital and it was indicated that the veteran reported that he had been having symptoms of a pilonidal cyst for four to five years. A pilocystectomy was performed in August 1942. The diagnosis on discharge was chronic pilonidal sinus, moderate to severe, and the cause was noted to be congenital. In May 1944 an infected pilonidal cyst was opened and drained. Later the same month the cyst was surgically removed. In June 1944 a diagnosis of recurrent pilonidal cyst, severe, with abscess formation, was made. The cyst was incised and drained in June 1944 and excision of the cyst was performed the following month. At the time of the veteran's October 1945 separation examination, he reported that he had had spine trouble for five and one-half months as the result of hauling coal. He indicated that his back was painful with lifting and that there was some drainage and marked weakness in the back. On examination, the veteran's back function was found to be normal. It was noted that a pilonidal scar was well healed. In a March 1946 statement a service associate of the veteran indicated that they were in the same company in late 1943 and 1944. The associate related that the veteran was hospitalized as a result of a serious back condition caused by hauling coal. A long time associate, in a March 1946 statement, related that the veteran was hospitalized for an infected cyst in service and that, according to the veteran, the condition was caused by a fall while practicing judo in service. O.O. Barker, M.D., concluded, after examining the veteran in March 1946, that the veteran had a very weak back and was unable to do heavy work. The veteran's former employer reported in a September 1946 statement that the veteran had worked for him from October 1945 through January 1946. The veteran, who did farm work, at times complained that his back and lower spine were bothering him. The former employer noted that the veteran had been hospitalized in service for a spinal injury resulting from a judo throw. An application for VA treatment for a back and spine condition was received from the veteran in October 1946. He reported that his symptoms were a weak back and an irritated back and spine condition. At the time of a December 1946 VA examination, the veteran complained of tenderness at the base of the spine. On examination, over the sacro-coccygeal region there was a long healed scar from previous operations. The skin was noted to be rather thin over these bony structures and a complete absence of subcutaneous tissue over the area was observed. There was slight atrophy of the muscles of the buttocks adjacent to the scar. The diagnoses included cicatrix, pilonidal region, with loss of subcutaneous tissue over the sacrum and coccyx. In June 1951 the veteran was advised that he was temporarily disqualified for retention in the active Reserve by reason of a draining pilonidal sinus. Later the same month he was examined by R. G. Sheppard, M.D. He reported that, at the inferior portion of the fifteen centimeter post-operative scar overlying the sacrum and coccyx, there was a red, tender indurated area, three centimeters in diameter, surrounding a punctate skin opening. There was a small amount of purulent drainage. Dr. Sheppard observed that the persistent pilonidal sinus tract would cause intermittent difficulties if the area were traumatized. At the time of an August 1951 VA examination, the veteran related that he was experiencing pain in the lower spine as well as slight drainage at times. He indicated that, after riding in a car or sitting for three or four hours, he had to get up and about to relieve the pain. On examination, no abnormalities of the musculoskeletal system were reported. The scar of the sacrum was described as wide and partly adherent. VA outpatient treatment records show that in February 1977 the veteran complained of soreness of the right hip lateral to the sacroiliac joint. X-ray examination revealed no significant bony or articular abnormalities of the sacroiliac joints. Some osteoarthritic spurs were noted in the lower lumbar bodies. In December 1988 he reported that there had been a gradual worsening of his low back pain over the last two years. A VA examination was conducted in April 1989. The veteran's medical history was reported to include low back injuries from falling on his tail bone after being flipped several times while involved in judo and from carrying coal. The surgical procedures conducted in 1942 and 1944 for the pilonidal cyst as well as treatment for infections were noted. Following a physical examination and X-ray examination, the diagnoses were status post multiple surgeries for pilonidal cyst with residuals of intermittent activity manifested by drainage and local discomfort, and also residual of healed cicatrix, likely an indication of incomplete excision of pilonidal cyst; no evidence of intra-articular arthritis of the hips; and extensive degenerative changes from the third lumbar vertebra to the first sacral vertebra. It was the examiner's opinion that the pilonidal cyst and residuals were not related to hip or spine discomfort or changes. The examiner was of the opinion that the lumbosacral spine changes, as documented, may reasonably be related to injuries the veteran claims to have sustained and that the changes could be causing the pain referred to the hips. Raymond H. Smith, M.D., an internist, in an August 1989 report, indicated that he evaluated the veteran's lumbosacral spine because of his chronic pain. It was noted that the veteran related the pain back to 1942 when he was injured in judo training. It was indicated that, ever since the several surgeries in service with excision of a wide area of soft tissue down to the coccyx, the veteran experienced low back pain upon sitting, prolonged standing, hyperextension or prolonged flexion. Dr. Smith reported that X-rays showed sclerosis and near total bone fusion of the fourth and fifth lumbar and first sacral vertebral processes in a sclerotic appearance of prolonged arthritis and wear and tear. It was observed that the area looked like post surgical change upon attempted fusion as is normally seen in a lumbar laminectomy. After a physical examination, Dr. Smith stated that it was his opinion that the veteran had chronic long term destructive/ degenerative arthritis of the lumbosacral spine with appropriate symptomatology consistent with mild radiculopathy and sciatica into the buttocks, predominantly on the left secondary to long- standing splinting in the lumbosacral area because of the surgery in 1942 through 1944 on the pilonidal cyst. The physician concluded that he thought the veteran had some disability secondary to surgery on the coccyx and the veteran's war injury aggravating a pilonidal cyst and the attempted resection during service. In a November 1989 report, John T. Lynn, M. D., a Diplomate, American Board of Internal Medicine and Rheumatology, noted the veteran's past medical history relating to his low back. After conducting a physical examination and an X-ray examination, Dr. Lynn's impressions were that the veteran's low back pain was related to degenerative disc disease and osteoarthritis. It was observed that the advanced osteoarthritis may have been initiated by the significant fall the veteran took during a judo match. The physician noted that the coccyx pain could be related to arthritic changes not visible on the coccyx film from debridement of his post operative infection following surgical correction of a pilonidal cyst in service. Dr. Lynn stated that he considered the veteran's pain to be related to degenerative disc disease and osteoarthritis secondary to low back injury and coccyx surgical debridement. The veteran testified at a personal hearing at the the RO in December 1989. He related that he had sustained an injury to his tailbone when he was thrown over the shoulder of a fellow trainee during a judo match. He had not sought treatment post service for his back problems because he had been told nothing could be done. In an October 1990 statement, Dr. Lynn indicated that it was his belief that the veteran's sacral and coccygeal pain was the result of osteoarthritis from prior debridement of a pilonidal cyst that had caused gangrene during service. Dr. Smith, in an October 1990 statement, related that it was his belief that the veteran's chronic arthritis started with the fall and subsequent surgeries to the coccyx and sacrum. The physician noted that the veteran's case was very similar to that seen in post-traumatic back degenerative/osteoarthritic changes in motor vehicle accidents, horse injuries and skiing accidents, and usually do not show up immediately upon the occurrence but take years to develop and are due to chronic strain on the joints in the affected area. An orthopedic evaluation of the veteran was conducted by the VA in May 1993. The VA orthopedic consultant, after reviewing the veteran's claims files, examined the veteran. The diagnoses were continued pain over the coccyx region secondary to previous pilonidal cyst surgery, tender scar; and degenerative arthritis of the second lumbar through first sacral vertebrae, evident on radiographs which the veteran provided. The orthopedic consultant indicated that he had reviewed all available medical records, consulted standard textbooks regarding pilonidal cyst surgery and complications therefrom and conducted a literature search regarding the possible relationship of pilonidal cysts/cyst surgery and secondary degenerative spinal arthritis. It was the consultant's opinion that there was no relationship, without resorting to speculation, between the veteran's pilonidal cyst and multiple surgeries and his currently diagnosed lumbosacral spine degenerative arthritis. William J. Ciccone, M.D., a Diplomate, American Board of Orthopaedic Surgery, reported in June 1993 that he had examined the veteran for low back problems. After noting the veteran's medical history, it was observed that the veteran had significant osteoarthritic degenerative changes. Dr. Ciccone stated that a portion of the veteran's injuries were secondary to his judo throw and aggravation of the pilonidal cyst. The physician concluded that it can take a long time for post-traumatic arthritic changes to appear and that a portion of the veteran's injuries were post-traumatic. Robert E. Carlton, M.D., a Diplomate, American Board of Orthopaedic Surgery, also reported examining the veteran in June 1993. In his report, it was related that he obtained a medical history from the veteran, examined him and reviewed 1989 X-ray films from Dr. Lynn. Dr. Carlton stated that he was of the opinion that the veteran's lower lumbar spine complaints and limitations were secondary to degenerative arthritis which could be reasonably related to the injury he sustained while in service. It was noted that this seemed to be a rather common occurrence with people with previous motor vehicle accidents or accidents involving falls in the lumbosacral area, such as being thrown from a horse. In October 1994 the Board requested an opinion from an independent medical expert addressing the questions of the likelihood that the veteran's currently manifested degenerative changes of the lumbosacral spine were post-traumatic and the likelihood that the currently manifested degenerative changes of the lumbosacral spine were related to the pilonidal cyst and/or associated surgery. Stephen I. Esses, M.D., a Professor of Clinical Orthopedic Surgery at Baylor College of Medicine, in a written response dated in October 1994, stated that no epidemiologic study had shown that occasional falls or heavy labor in any way contributes to the development of degenerative disease. He stated that he was of the opinion that the veteran's currently manifested degenerative changes were not the result of a fall during judo training or heavy labor. Dr. Esses related that it was his opinion that there was no evidence whatsoever in the literature that a pilonidal cyst or surgery for a pilonidal cyst would ever result in any change in the lumbosacral spine. Dr. Ciccone, in a December 1994 statement, reported that he was shown a letter that the veteran had received from Dr. Esses. Dr. Ciccone related that he disagreed with that letter, noting that he felt that trauma played a significant role in the development of arthritic changes in the low back. He concluded that certainly the trauma the veteran sustained in all probability would play a definitive causal relationship to the back problem. In a December 1994 statement, Dr. Carlton reported that it would be his opinion, concurrent with the opinion of the VA physician in 1989, that the X-ray changes in the veteran's lumbosacral spine could be reasonably related to injuries the veteran sustained in 1942. It was noted that the pain in his hips was felt to be most likely referred, as the veteran's X-ray changes were very minimal for any degenerative changes. Initially, the Board notes that service connection has been in effect since October 1945 for the postoperative residuals of a pilonidal cyst, currently evaluated as 10 percent disabling. The veteran contends, in effect, that his current degenerative changes of the lumbosacral spine with referred hip pain are the direct consequence of a judo throw injury and/or heavy labor, or, in the alternative, due to the multiple surgical procedures performed for a draining pilonidal cyst. There are extensive service medical records concerning the treatment received by the veteran for a draining and infected pilonidal cyst, but these records make no reference to a judo throw injury. Although it has been stated that his pilonidal cyst condition was initiated by the judo throw injury, the medical history taken at the time of his hospitalization in August 1942 reveals that he had a 4-5 year history of a pilonidal sinus. Again, no mention was made of a judo throw injury. The report of the veteran's service separation examination, conducted in December 1945, notes that he had had back symptoms related to loading coal, but also fails to refer to a judo injury or residuals thereof. Post-service medical records indicate that the veteran continued to experience symptoms related to the pilonidal cyst. Although he expressed complaints regarding his back, on VA examinations conducted in October 1946 and August 1951, no lumbosacral abnormalities were evident. Arthritis of the lumbosacral spine was initially identified by X-rays taken in February 1977, over 3 decades subsequent to the veteran's separation fron military service. No records of treatment for a lumbosacral spine condition prior to 1977 have been presented. The statements submitted by service associates and other acquaintances of the veteran are of little probative value in the determination as to whether his service experiences were the cause of his current back condition as they are based on a history provided by the veteran or are otherwise inconsistent with the record. Although these statements suggest that the veteran was having problems with his back during the years following his discharge from service, as discussed above, no such pathology was found on VA examinations in 1946 and 1951. Opinions have been provided by several private physicians to the effect that the currently demonstrated degenerative changes of the lumbosacral spine with referred hip pain are directly related to the judo throw injury reported by the veteran and/or the surgical procedures performed for a draining pilonidal cyst. Two of these physicians, Drs. Ciccone and Carlton, are board- certified orthopedists, and a third, Dr. Lynn, is a board- certified rheumatologist.The weight given to their opinions, which under most circumstances would be significant given their expertise, is diminished by the erroneous or incomplete history, provided by the veteran, upon which their conclusions were based. Reonal v. Brown, 5 Vet.App. 458 (1993). For example, Dr. Carlton's December 1994 statement indicates that the veteran had low back pain and pain across his hips following the 1942 judo injury and was unable to do any significant lifting. As noted previously, the August 1942 hospitalization report and subsequent service medical records make no mention of a judo injury or of low back or hip pain. Dr. Ciccone's December 1994 statement notes that the veteran was hospitalized for between 4 and 5 months following the judo throw injury for treatment of disk and nerve problems. In fact, service medical records disclose no such treatment. The veteran was hospitalized from May to September 1944 for treatment of a draining pilonidal sinus, not disk or nerve problems. The opinions presented by the VA examiner in April 1989, Dr. Smith, and Dr. Lynn are similarly flawed by their reliance on the medical history provided by the veteran. To the contrary, the VA orthopedic consultant who examined the veteran in May 1993 and the independent medical expert who provided a written opinion in October 1994 both indicated that they had reviewed the entire record, both service and post service. Further, both of these physicians referred to scientific literature in support of their conclusions that the veteran's current lumbosacral pathology is not related to an inservice judo throw injury or surgeries performed for a pilonidal cyst. Accordingly, the Board finds that these opinions are of significant probative value. In reaching its decision, the Board has taken into account the testimony provided by the veteran at a personal hearing. Nevertheless, for the above reasons and bases, the Board concludes that the preponderance of the evidence in its entirety is against the claim for service connection. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.307, 3.309. ORDER Entitlement to service connection for degenerative arthritis of the lumbosacral spine with referred hip pain is denied. WAYNE M. BRAEUER 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. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.