Citation Nr: 0003254 Decision Date: 02/09/00 Archive Date: 02/15/00 DOCKET NO. 94-44 083 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUE Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Maine Division of Veterans Services WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel INTRODUCTION The veteran had active service from July 1955 to July 1959. This appeal arises from an August 1993 rating decision of the Togus, Maine Regional Office (RO) which denied entitlement to service connection for a back disability. The case was remanded from the Board to the RO in June 1996 and in October 1997 for additional development of the evidence. The veteran testified at a videoconference hearing in November 1999 before the undersigned member of the Board. FINDINGS OF FACT 1. All available relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. Disability of the low back, to include arthritis, was first manifest many years after separation from service. 3. It is more likely than not that disability of the low back is unrelated to service. 4. An independent medical opinion is not deemed necessary as the issue presented is not so complex or controversial as to require such an opinion. CONCLUSIONS OF LAW 1. The veteran has submitted evidence of a well grounded claim concerning service connection for a low back disability. 38 U.S.C.A. § 5107(a) (West 1991). 2. A low back disability was not incurred in or aggravated by the veteran's period of active service, nor may arthritis be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1999). 3. An advisory opinion from an independent medical expert is not warranted. 38 U.S.C.A. §§ 5107, 7109 (West 1991); 38 C.F.R. § 20.901(d) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual background The service medical records show that the veteran was treated on 21 and 22 August 1956 for gastritis, pain of the right lower quadrant, vomiting and diarrhea. He was admitted to the sick bay. On 23 August 1956, the veteran was flown by helicopter to a USAF hospital after being ill for 48 hours. The veteran was acutely ill with signs of generalized peritonitis. Under spinal anesthesia, the abdomen was entered through a Rocky-Davis incision. There was generalized peritonitis and the small bowel and omentum were bound by fibrinous adhesions to the right lower quadrant where the suppurative appendix was dissected free. The appendix lay beside the terminal ileum which was inflamed and had a markedly thickened wall. The appendectomy was performed with inversion of stump without ligation. On the first post-operative day, the veteran had icteric sclerae which increased by the second postoperative day and then gradually disappeared. Abdominal distention increased although the veteran complained of no discomfort other than fullness. The veteran never reported colicky pain. X-rays of the abdomen showed distention of small bowel. When this condition remained unchanged, a Miller-Abbott tube was introduced on the 5th postoperative day. The small bowel satisfactorily decompressed. The veteran was maintained on parenteral fluids for 9 nine days. The Miller-Abbott tube was removed after 4 days. The subsequent postoperative course was satisfactory other than a small amount of sero-purulent drainage from the abdominal wound for a few days. Penicillin and Streptomycin were discontinued on 4 September and Terramycin was discontinued on 13 September. The veteran was discharged to rejoin his ship on 17 September. The diagnoses were acute appendicitis with perforation; acute generalized peritonitis, organism undetermined; postoperative ileus; and post operative jaundice, etiology unknown. The veteran had been in the hospital for 25 days. On the July 1959 separation examination, the abdomen, viscera and spine were clinically evaluated as normal. The veteran filed the instant claim for a back disability in July 1993. He indicated that he had received treatment for the back since 1992. A July 1993 statement from Harry Lowell, D. O., indicates that there were no records for the veteran as the physician had never seen the veteran. A July 1993 VA outpatient treatment record shows that the veteran complained of low back pain that he had for years. The pain had grown worse. Reportedly he had been told that he had a "disease of the back" 20 years before. On examination, there was no pain to palpation over the spine. There was no costovertebral angle tenderness. Straight leg raising was to 60 degrees bilaterally. The diagnostic impressions included low back pain. Received in December 1993 were private medical records dating from December 1979 to October 1993. In August 1988, complaints included low back stiffness in the morning that slowly improved during the day. On the January 1994 substantive appeal, the veteran indicated that he had permanent back problems due to spinal taps that had been administered in service. The veteran testified in August 1994 that spinal taps during service were not placed properly, that spinal taps were administered 3 times, that he received treatment for his back over the years since service, that a VA physician told him in 1973 that he had a "disease" of the back, and that he could not bend and his reflexes were gone when he first got out of the hospital during service. The veteran's written statement, received in August 1994, indicates that following the inservice surgery the veteran suffered from constant low back and hip pain that he had just lived with. An October 1995 statement from the National Archives indicates that deck logs for the USS Tanner for 1956 had been located. The veteran could pay for these records by credit card. By letter from the RO to the veteran in November 1995, he was informed that he could follow the directions from the National Archives if he wished to obtain deck logs. A January 1996 VA outpatient notation indicates that there was no change in the veteran's symptoms. A CT scan show disc space narrowing of L3, 4, and 5, but little change if any since 1993. There was no evidence of spinal stenosis. The assessment was bulging disc of the lower lumbar spine. A July 1996 statement from Donald Dubois, M. D., indicates that the veteran had been followed for at least 4 years for disabilities to include chronic low back pain. The veteran related a history of low back pain dating back to the 1950s. In 1956, he had abdominal symptoms and he underwent surgery for a ruptured appendix. In preparation for surgery, 3 attempts at lumbar puncture were unsuccessful. He required general anesthesia for the operation. During the post operative period, the veteran related a loss of sensation and motor function from the belly button down. This description was consistent with a spinal lesion at L4, the area usually used for lumbar punctures. Over the following days, the veteran had gradual return of most function though he continued to have an area of decreased sensation in the suprapubic area and loss of deep tendon reflexes of the lower extremities. The veteran did not relate a history of chronic bowel or bladder dysfunction, drop foot, classic sciatica or other problems suggestive of related diagnoses. In addition, since that time, the veteran had activity limitation because of low back stiffness and pain. The back symptoms had progressed over the years limiting his work abilities. At the present time, an examination revealed an area of decreased light touch sensation to the skin of the suprapubic region. There was no scoliosis or decreased range of motion. There was adequate distraction of posterior spinal elements. The lower extremities showed normal muscle tone and bulk. The veteran had no demonstrable deep tendon reflexes at the knees or ankles. Toes were down going and sensation to light touch, vibration, and proprioception were intact. Dr. Dubois indicated that he did not have specific records to confirm the veteran's stated history. There apparently existed a controversy as to whether the veteran's current back problems related to the attempted lumbar punctures in 1956. Dr. Dubois noted that it was not possible for him to prove cause and effect; however, it was interesting and suggestive to note that the post operative symptoms the veteran reported were consistent with a spinal cord event at the level of L4. As a result, Dr. Dubois opined that there was a possibility that the lumbar punctures and the subsequent symptoms were related. In July 1997, the National Personnel Records Center (NPRC) indicated that a more extensive search of additional medical records produced no records for the veteran. The RO sent the veteran a development letter in January 1998 requesting that he complete and return the enclosed VA Forms 21-4142 for all physicians or facilities where he had received treatment for back disability since separation from service to include Damon Chiropractic Clinic and the Rehabilitation Center in Manchester, New Hampshire. By way of response, the veteran submitted a statement and a medical authorization for Karl Sanzenbacher, M.D. Dr. Sanzenbacher's treatment reports are of record. In January 1998, the Togus VA medical center indicated that there were no VA outpatient treatment records in the current file for the veteran dating from the 1970s. In 1998, the following records were received from Dr. Sanzenbacher. A mid-December 1996 treatment note from Dr. Sanzenbacher indicates that the veteran had a history of low back pain going back to the 1950s. He ascribed this to an episode when an emergency appendectomy spinal anesthesia was attempted with multiple lumbar punctures. The veteran reported pain since that time. He described an area of decreased sensation extending from the umbilicus to the suprapubic area. Afterward, this area of decreased sensation subsequently disappeared. He felt that this problem had become progressively worse. The veteran's service medical records were not available. He believed that his reflexes were gone in his legs. He had had decreased range of motion of the back. On sensory examination, there was a decrease to cold in a stocking like fashion from a point just above the knee distally on the left and below the knee distally on the right. Sensation to pin was intact over the peroneum, scrotum and penis. Straight leg raising could be performed to 30 degrees bilaterally. With Patrick tests, the veteran referred to pain of the lower back bilaterally. In a standing position, the veteran could forward flex to 45 degrees. Bilateral flexion was full. Hyperextension was limited to about 5 degrees. The question was raised as to whether the veteran's problems related to an old injury or were superimposed to other problems. In any case, the possibility of a lumbar radiculopathy was in the differential diagnosis. The possibility that the veteran had an arachnoiditis due to spinal anesthesia was also in the differential diagnosis. In late December 1996, Dr. Sanzenbacher indicated that the veteran continued to have low back pain. Currently, there was markedly diminished knee jerks. The examiner was concerned with L4-5 radiculopathy. A January 1997 treatment note from Dr. Sanzenbacher indicates that the question was raised of whether the veteran had Forestier's disease on his routine lumbosacral spine films. This was an idiopathic calcific hyperostosis which could be progressive but it was unclear whether the veteran actually had such a condition. Most of the findings on current examination pointed to the L4-L5 area. Dr. Sanzenbacher indicated in February 1997 that an MRI had showed some indentation of the dural sac at L4-5. This lateralized more to the right. Dr. Sanzenbacher questioned whether axial views might show some neural compromise, although the radiologist did not feel that this was significant. A March 1998 notation from the NPRC indicates that the veteran's service medical records were sent to VA in August 1993. No sick logs were available from unidentified places. Hospital records could not be located without the date and year of hospitalization. Treatment records were received in 1998 from Arthur Weisser, D.O. In June 1997, the veteran was seen for chronic back pain. Multiple injections were administered to the back. Later that month, it was noted that the veteran's back had not gotten any better from the shots. In July 1997, the veteran complained of lumbar and dorsal pain. Manipulative therapy was administered. The diagnosis was somatic dysfunction. A March 1998 notation to the folder shows that the veteran was being scheduled for an orthopedic examination and that his claims folder was to be made available to the examiner. On VA orthopedic examination in April 1998, it was noted that the veteran's physical discharge examination from service was totally negative for a low back condition. The veteran claimed that following the inservice appendectomy, he lost all feeling in the legs and that he no longer had any lower extremity reflexes. The veteran emphasized that he never had any accidents, and he related the onset of his low back problems to the unsuccessful spinal taps in service. The veteran reported that a MRI that was conducted a year and a half before did not show anything. Reportedly, the physician did not think that needles "could do this." On examination, flexion of the spine was to 80 degrees, lateral bending was to 10 degrees, and bilateral rotation was to 15 degrees. Extension was good at 10 degrees. Toe and heel walk were performed well. There were no motor or sensory deficits in the lower extremities. The hips and pedal pulses were okay. Bilateral straight leg raising was to 45 degrees. X-rays of the lumbar spine revealed osteophyte formation and degenerative changes at multiple levels. The facet joints in the lumbosacral area were particularly affected by arthritic changes. The impression was hypertrophic spondylosis of the lumbar spine. The examiner noted that there was no indication of nerve root compression in spite of osteoarthritic encroachment on neural foramina at L-4 and L-5. The discharge examination from service in July 1959 was negative. The military records revealed no entries regarding low back problems. The veteran's present problems were secondary to arthritis and were thought to have developed after leaving the service. The present problems were not due to spinals in 1956. In May 1999, the veteran requested that his case be referred for an independent medical opinion due to the medical complexity of his claim. A May 1999 statement from Dr. Weisser indicates that he had treated the veteran since May 1997 for undisclosed conditions which he felt were directly related to the injuries the veteran received in service. Received in June 1999 was a statement from a long time friend of the veteran who indicated that the veteran was a good athlete prior to service, that he had an operation in service that caused permanent back problems to include pain, that the veteran tried to play ball after service, and that back pain had caused him to change his lifestyle. A June 1999 statement from the veteran's sister indicates that when the veteran returned home after service his back really bothered him and he started receiving treatment from a local physician, and that back problems had grown worse through the years. The veteran testified in November 1999 that his back started bothering him right after the surgery in service, that he had trouble with his back ever since, that he had back numbness, that he first received back treatment after service in 1960 from a chiropractor, that these initial post service medical records were not available, that he first received VA treatment in 1972 or 1973 at the Togus VAMC when a physician told him that he had a disease of the back, and that Dr. Weisser told him that surgery in the military service could have caused his back problems. II. Analysis Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if preexisting such service, was aggravated by service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946 and arthritis becomes manifest to a degree of ten (10) percent or more within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A claimant seeking benefits under a law administered by the Secretary of the Department of Veteran Affairs shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The Secretary has the duty to assist a claimant in developing facts pertinent to the claim if the claim is determined to be well grounded. 38 U.S.C.A. § 5107(a). Thus, the threshold question to be answered is whether the veteran has presented a well grounded claim; that is a claim which is plausible. If he has not presented a well grounded claim, his appeal must fail, and there is no duty to assist him further in the development of his claim as any such additional development would be futile. Murphy v. Derwinski, 1 Vet. App. 78 (1990). To sustain a well grounded claim, the claimant must provide evidence demonstrating that the claim is plausible; mere allegation is insufficient. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). The determination of whether a claim is well grounded is legal in nature. King v. Brown, 5 Vet. App. 19 (1993). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). To be well grounded, a claim must be accompanied by supportive evidence, and such evidence must justify a belief by a fair and impartial individual that the claim is plausible. Where the determinative issue involves a question of either medical causation or diagnosis, medical evidence is required to fulfill the well grounded claim requirement of 38 U.S.C.A. § 5107(a). Lathan v. Brown, 7 Vet. App. 359 (1995). Establishing a well-grounded claim for service connection generally requires medical evidence of a current disability, see Rabideau v. Derwinski, 2 Vet. App. 141 (1992); medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well- grounded claim set forth in Caluza, supra), petition for cert. filed, No. 97-7373 (Jan. 5, 1998); Heuer v. Brown, 7 Vet. App. 379 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). Alternatively, under 38 C.F.R. § 3.303(b) (1999), service connection may be awarded for a "chronic" condition when: (1) a chronic disease manifests itself and is identified as such in service (or within the presumption period under 38 C.F.R. § 3.307 (1999)) and the veteran presently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period) but is not identified until later, there is a showing of continuity of symptomatology after discharge, and medical evidence relates the symptomatology to the veteran's present condition. See Savage v. Gober, 10 Vet. App. 488, 495-98 (1999). With regard to the well groundedness of the instant claim, the Board noted in the October 1997 remand that Dr. Dubois' July 1996 opinion was sufficient to render the veteran's claim well grounded. The October 1997 determination by the Board that the veteran's claim was well grounded establishes the law of the case for the purposes of the adjudication of this appeal. In other words, the Board may not now supersede that determination. The Board is also satisfied that no further assistance is required to comply with the duty to assist under 38 U.S.C.A. § 5107(a). In this regard, the RO was directed in the October 1997 remand to obtain all available medical records. By letter in January 1998 from the RO to the veteran, it was requested that he supply information and medical authorization forms relative to all medical treatment for the low back since discharge from service. By way of response, the veteran indicated that he was submitting treatment records from Dr. Sanzenbacher; Dr. Sanzenbacher's treatment notations from December 1996 to February 1997 are of record. Records were also received in March 1998 from Stephen Dyks, D.C. Additional treatment records from 1997 to 1999 and a statement were received from Dr. Weisser. With regard to VA and service department records, the veteran was informed in November 1995 that he could obtain deck logs if he wished to pay for copies. No response was received from the veteran. The Togus VAMC indicated in January 1998 that there were no outpatient treatment records for the veteran from the 1970s. The NPRC indicated in July 1997 that no additional records were available and it was indicated in March 1998 that no sick logs were available. It was noted that additional specific information was necessary in order to attempt to obtain any further medical records. The veteran has not provided specific information as to the place or date of treatment of the low back during service, other than the August to September 1956 hospital records that are already of record. In addition to the above, the veteran testified in November 1999 that records were not available from Dr. Damon who treated him shortly after service. He further testified that records were not available from a rehabilitation clinic where he was evaluated. In view of the above efforts expended by the RO in the evidentiary development of this claim, it is clear that all available medical evidence relative to the veteran's back disability has been obtained. Moreover, the veteran was afforded a VA orthopedic examination in April 1998 to include a medical etiology opinion regarding disability of the low back. The claims file also shows that the veteran was in receipt of Social Security Administration (SSA) disability benefits. The Court has held that the VA has a duty to attempt to secure all records of the SSA regarding the veteran's rating of unemployability for SSA purposes. Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992). The Board finds, however, that a remand of this claim for purposes of obtaining SSA records is not warranted. There is no indication that the contents of any of the SSA records would show a relationship between the veteran's service and any post service low back disability, nor has it been otherwise contended. Thus, no useful purpose would be gained in further delaying a decision in this case by requesting SSA records. Accordingly, the Board finds that the duty to assist in the development of the veteran's service connection claim has been met. 38 U.S.C.A. § 5107(a). The service medical records to include the July 1959 separation examination report are silent regarding complaints, clinical findings or diagnoses of a low back disability. When the veteran filed the instant claim in July 1993, he reported having received treatment for the back since 1992. The earliest post service medical records that have been obtained date from 1979 to 1993. These private medical records contain one reference to the back. In August 1988, the veteran complained of low back stiffness in the morning. Recent treatment records and diagnostic testing has demonstrated the presence of low back disability to include arthritis that was first manifest more than 30 years after separation from service. The above medical evidence is augmented by 2 medical opinions regarding the alleged connection between the inservice surgery and the post service development of a low back disability. The Board also notes that an additional statement was received from Dr. Weisser in May 1999; however, this statement lacks probative value. The statement is incomplete as it does not indicate what disability the physician believes is related to the inservice injury. Nonetheless, the analysis below relative to Dr. Dubois' opinion is equally applicable to Dr. Weisser's opinion. The Court has provided some guidance as to how the Board should approach the evaluation of medical opinions. In Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994), in discussing the Board's use of independent medical opinions (IME), the Court stated: An IME opinion is only that, an opinion....The VA claims adjudication process is not adversarial, but the Board's statutory obligation under 38 U.S.C. § 7104(d)(1) to state 'the reasons or bases for [its] findings and conclusions' serves a function similar to that of cross-examination in adversarial litigation. The BVA cannot evade this statutory responsibility merely by adopting an IME opinion as its own, where, as here, the IME opinion fails to discuss all the evidence which appears to support appellant's position. Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. There are substantial and significant factors which favor the valuation of the April 1998 VA medical opinion over Dr. Dubois' July 1996 medical opinion in the instant case. Dr. Dubois, in July 1996, indicated that he had treated the veteran for 4 years. Thus, more than 30 years had transpired between separation from service and the initiation of Dr. Dubois' medical treatment of the veteran. Of even greater significance is the fact that Dr. Dubois noted that his opinion was based solely upon the veteran's medical record as related to him by the veteran. Dr. Dubois stated that he had no specific records to confirm the veteran's medical history. In this regard, there are several important discrepancies between what the veteran has reported to medical providers in recent years as compared to what the contemporaneous inservice hospital records demonstrate. The veteran has stated that there were 3 failed attempts to administer spinal taps. The inservice hospital record does not reflect that multiple attempts were necessary to administer a spinal tap. The record simply states that spinal anesthesia was administered. The veteran testified that his back started bothering him right after surgery and that he had trouble with the back ever since. The hospital report shows that abdominal distention increased after surgery, but the veteran complained of no discomfort other than fullness. The distention was relieved following a surgical procedure and thereafter the subsequent postoperative course was satisfactory except for a small amount of purulent drainage. The veteran has indicated that after surgery he suffered from decreased sensation of the suprapubic area. The service medical records and the early post service medical records fail to reflect that the veteran complained of back pain or decreased sensation of the suprapubic area. The VA examiner who performed the April 1998 VA orthopedic examination reviewed the veteran's entire claims folder in association with the examination. The examiner accurately recounted the veteran's medical history relative to the low back, especially relating to the service medical records that were crafted contemporaneously with the inservice surgery. The examiner found it significant that at no point during the course of hospitalization in 1956 did the clinical findings involve the low back. Dr. Dubois, on the other hand, relied entirely on the veteran's flawed oral history. Dr. Dubois indicated that he could not prove cause and effect; nonetheless, he noted that it was interesting and suggestive that the post surgery symptoms as reported by the veteran were consistent with a spinal cord event. Unfortunately, the post surgery symptoms reported by the veteran to Dr. Dubois in 1996 are completely at odds with the symptoms that the veteran contemporaneously reported to the military physicians in 1956. Dr. Dubois then opined that there was a possibility that the spinal taps and subsequent symptoms were related. The possibility of a nexus as opined by Dr. Dubois runs contrary to the medical evidence of record. In short, Dr. Dubois' opinion as to the existence of a current low back disability related to service is wholly based on conjecture and lacks probative value. Conversely, the April 1998 VA medical opinion was based on an accurate review and assessment of the medical evidence. Therefore, it must be accorded significant probative value. The veteran has submitted personal statements and offered testimony along with statements from a friend and his sister to the effect that his current low back disability is the result of the inservice surgery. This evidence is insufficient to establish service connection. The Court has held that lay persons cannot provide testimony where an expert opinion is required. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Nothing in the claims file indicates that the veteran or his sister or friend are health care professionals or that they otherwise have any specialized training or knowledge in the science of determining etiologies of medical conditions. Therefore, the lay opinions offered are beyond the competence of the individuals offering them. Black v. Brown, 10 Vet. App. 279 (1997). Having considered the totality of the medical evidence, and in light of the applicable law and regulations, the Board concludes that it is more likely than not that the veteran does not currently have a disability of the low back that is related to his military service. Accordingly, the Board concludes that the preponderance of the evidence is against the veteran's claim. Finally, the veteran has requested an independent medical expert's opinion be obtained. The applicable criteria pertaining to independent medical expert opinions provide as follows: Independent medical expert opinions. When, in the judgment of the Board, additional medical opinion is warranted by the medical complexity or controversy involved in an appeal, the Board may obtain an advisory medical opinion from one or more medical experts who are not employees of the Department of Veterans Affairs. Opinions will be secured, as requested by the Chairman of the Board, from recognized medical schools, universities, clinics, or medical institutions with which arrangements for such opinions have been made by the Secretary of Veterans Affairs. 38 C.F.R. § 20.901(d). An independent medical examination is not deemed necessary in this case as the issue presented is not so complex or controversial as to require such an opinion. The medical opinions of record are considered sufficient to render an equitable decision in this case. ORDER Entitlement to service connection for a low back disability is denied. Iris S. Sherman Member, Board of Veterans' Appeals