BVA9500798 DOCKET NO. 91-42 587 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an increased (compensable) evaluation for fibrositis of the neck and shoulders with faciitis of the right shoulder. 2. Entitlement to service connection for low back disability. ATTORNEY FOR THE BOARD Lori J. Wells-Green, Associate Counsel INTRODUCTION The veteran served on active duty from December 1977 to December 1981 and from March 1982 to March 1990. This matter came to the Board of Veterans' Appeals (Board) on appeal from an August 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska, which granted her service connection for fibrositis of the neck and shoulders at a noncompensable rate, and denied service connection for low back disability. In November 1991 the Board remanded the case for further development. Thereafter, in November 1993, the Board granted service connection for cervical spine disability and remanded the case for still further development. The case has been returned to the Board for further appellate action. REMAND In the Board's November 1993 remand, it was requested that the RO arrange for VA evaluation of the veteran's claimed low back disability and secure the examiner's opinion as to whether any low back disability found to be present was etiologically related to complaints by the veteran of low back pain during service. A careful review of the veteran's claims file shows that she was treated several times for low back pain during service. Further, April 1994 VA X-ray studies of her lumbar spine were interpreted by the radiological examiner as showing evidence of osteophytosis anteriorly at L3-4. However, the April 1994 VA orthopedic examiner did not assess or comment with respect to the etiology of the veteran's low back disability or opine as to any possible causal relationship between the veteran's treatment for low back pain during service and her current disability, likely because he found no evidence of low back disease. He described the X-ray films as normal. In June 1994, the orthopedic examiner agreed with the radiologist, but offered no etiological opinion. The United States Court of Veterans Appeals has held that, under 38 U.S.C.A. § 5107(a) (West 1991), VA's duty to assist a veteran in obtaining and developing available facts and evidence to support a claim includes obtaining an adequate and contemporaneous VA examination which takes into account the records of prior medical treatment. Littke v. Derwinski, 1 Vet.App. 90 (1990). Further examination seems in order here. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that she identify specific names and addresses and approximate dates of treatment for all health care providers who have treated her for any back disability or for fibrositis of the neck and shoulders since service. Then, with any needed authorization from the veteran, the RO should attempt to obtain copies of all treatment records identified by the veteran which have not been previously secured. 2. When the foregoing development has been completed, the RO should arrange for a VA orthopedic examination of the veteran, if possible by an examiner who has not seen her before, to determine the nature and extent of the veteran's low back disability, as well as the current severity of her fibrositis of the neck and shoulders with fasciitis on the right. All indicated studies, to include x-rays and range of motion testing, should be performed. If necessary, correlation with the radiologist should be accomplished. If the examiner finds that a low back disability is present, he or she is specifically requested to give an opinion, with complete rationale, as to the etiology thereof, to include its relationship, if any, to the complaints of low back pain noted during service. Manifestations of the veteran's service-connected cervical disc disease should be distinguished from those of fibrositis, as far as possible. The veteran's claims folder should be made available to the examiner prior to his or her examination of the veteran. 3. Thereafter, in light of the evidence obtained pursuant to the requested development, the RO should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the veteran's satisfaction, a supplemental statement of the case containing adequate reasons and bases should be issued and the veteran provided an opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until she is notified by the RO. J. J. SCHULE 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) (1993).