BVA9502051 DOCKET NO. 93-09 761 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD E. A. Artman, Associate Counsel INTRODUCTION The veteran served on active duty from February 1959 to April 1962, and from November 1963 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) of the Department of Veterans Affairs (VA) on appeal from a March 1992 rating decision of the Los Angeles, California, Regional Office (RO). REMAND At a hearing conducted by a Board member at the RO in April 1993, the veteran asserted that the low back disorder, for which he claims service connection, had progressed since service, to the extent that it was best-categorized at the time of the hearing as a disc disorder of the lumbosacral spine. His testimony regarding his inservice injury and treatment of his lower back is fully substantiated by service medical records. These records show that the veteran was hospitalized for low back pain for eight days in February 1967, and that the veteran again complained of low back pain in late 1970. A November 3, 1970 outpatient entry shows that the veteran was considered to have acute severe lumbosacral strain with marked muscle spasm of the paravertebral muscles. An orthopedic consultation performed a few days thereafter, on November 9, 1970, yielded an impression of paraspinal muscle spasm. X-rays studies completed at that time were noted on the consultation report to be negative for abnormalities other than the presence of spina bifida at the level of S-1. As acknowledged by the veteran at his hearing, his October 1971 separation examination report does not disclose any complaints of ongoing symptomatology of a back disorder, but does document the inservice episodes of back sprain. The veteran claims that he did continue to experience low back pain from 1970 until the time of his discharge; that the pain was a recurrent problem in the first year or two following his service; and that he "re-injured" his back during this time when he performed job-related heavy lifting. Transcript of Hearing 6 (April 1, 1993). The veteran further testified that he re- injured his back on several subsequent occasions as a result of heavy lifting or lifting objects over his head, and that, in each such instance, he experienced the same feeling of pulled muscles in the same area of his back. In support of these contentions, the veteran submitted copies of records pertaining to Workers' Compensation claims -- claims which were filed as a result of injuries incurred to the lower back in November 1975, October 1985 and March 1986. An attending doctor's report, dated on what appears to be October 26, 1985, lists a diagnosis of lumbosacral strain and affirmatively indicates that the veteran's injury earlier that month could result in permanent restriction or total or partial loss of function of his back. In addition, the veteran submitted treatment reports from Gallatin Medical Clinic of Downey, California, which show that the veteran was treated at that facility in September 1991 for lumbosacral strain. Given this evidence, it appears to be clear that the veteran has experienced several problems affecting his lower back both during and subsequent to his period of active service. However, the evidence fails to establish the nature of the relationship, if any, between these problems. It is not possible to ascertain from the medical evidence submitted whether those that have provided care in the past viewed the most recent episode of back pain as part of an ongoing disorder or pathology, or whether they chose to view the episode as an isolated incident, capable of full resolution once the triggering injury was healed. Without this understanding of the evidence, no determination can be reached with regard to the veteran's claim of service connection. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.301, 3.303(d) (1993). Consequently, it is necessary to refer the claim to the RO for additional development of the evidence. Accordingly, this case is REMANDED for the following actions: 1. The RO should attempt to obtain copies of treatment records pertaining to the veteran's back disorder from: (1) any VA facilities from which the veteran may indicate he has received treatment, and, with any needed assistance from the veteran, (2) those private physicians and facilities identified as providing care for his claimed disorder on the VA Form 21-526, Veteran's Application for Compensation or Pension, received by the RO in January 1992. All records received should be associated with the veteran's claims file. 2. Upon completion of step (1), a VA examination of the veteran's back condition by a board-certified or board-qualified orthopedist should be arranged. A complete diagnosis of any low back disorder(s) found to exist should be provided in accordance with the guidelines set forth in VA's Physician's Guide for Disability Evaluation Examinations (IB 11-56, Mar. 1, 1956). It is requested that any diagnosis be accompanied with an opinion as to the etiology of the identified disorder. Such an opinion should expressly address whether any causal relationship may be said to exist between the identified disorder and events of the veteran's service. To this end, his claims file should be made available for the examiner's review prior to the examination. All of the examiner's opinions and conclusions should be set forth in detail. 3. Based on the evidence obtained pursuant to the development sought above, the RO should take all indicated adjudicatory action. If the benefit sought by the veteran on appeal is not granted, a supplemental statement of the case should be issued. After the veteran and his representative have been given an opportunity to respond to the supplemental statement of the case, the claims file should be returned to this Board for further appellate review, if otherwise in order. No action is required by the veteran until he receives further notice. The purpose of this REMAND is to procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the disposition of this appeal. 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).