BVA9506442 DOCKET NO. 93-10 877 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 50 percent disabling. 2. Entitlement to an increased evaluation for a thoracic and lumbar spine disability, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. K. Mulroy, Associate Counsel REMAND The veteran had active duty from June 1966 to October 1970. The veteran was originally granted service connection for proliferative changes, minimal, thoracolumbar spine, which was determined to be noncompensable, in a decision dated in March 1971, by a local regional office. The New Orleans, Louisiana, Regional Office (hereinafter the RO) granted service connection for post-traumatic stress disorder in a decision dated in July 1987, and assigned a 30 percent disability evaluation. In a decision dated in August 1988, the RO recharacterized the back disability as proliferative changes thoracic, lumbar spine, and increased the evaluation for his back disability to 10 percent. In a decision dated in September 1989, the Board of Veterans' Appeals (hereinafter the Board) determined that a further increase in the back disability evaluation was not warranted. In a rating decision dated in April 1990, the RO increased the evaluation for post-traumatic stress disorder to 50 percent. This evaluation was confirmed in several subsequent decisions by the RO, most recently in a decision dated in July 1991, from which the veteran has appealed. In a decision dated in March 1992, the RO increased the back disability, recharacterized as proliferative changes, thoracic and lumbar spine, to 20 percent. The veteran has added this issue to his appeal. The veteran is represented by the Disabled American Veterans. The veteran contends that his post-traumatic stress disorder warrants an evaluation greater than the currently assigned 50 percent. He maintains that due to the disorder, he is suicidal, has marital problems, in general does not associate with people, desires to kill people who wrong him, does not like or trust people, and experiences nightmares, flashbacks and guilt feelings. The veteran also alleges that his back disability has worsened, and that he experiences pain over the entire thoracic and lumbosacral spine, which is aggravated by weather changes, sneezing, bending, lifting, standing in excess of 5 minutes, and walking in excess of 15 minutes. He also complains of stiffness of the dorsolumbosacral spine, radiation of pain into his shoulders and lower extremities with sciatica, and tingling and numbness of the lower extremities without motor weakness. The Department of Veterans Affairs (hereinafter the VA) has a duty to assist in the development of the evidence pertinent to the veteran's claim. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.103 (1993). It is noted that the veteran has not been afforded a VA psychiatric examination since June 1991. In order for a fair determination of the appropriate disability evaluation, the present level of disability is of primary concern. The Board concludes that a remand is appropriate in order to afford the veteran a contemporary psychiatric examination. The Board also notes that in a VA examination dated in January 1971, x-rays were interpreted as revealing proliferative changes of the lumbar spine including the lower three or four thoracic vertebrae, and a developmental anomaly of a downward tilt of the sacrum. Based upon the evidence of record at that time, the RO granted service connection for one disability characterized as proliferative changes of the thoracolumbar spine, and rated the disability on the basis of arthritis under 38 C.F.R. Part 4, Diagnostic Code 5003. Subsequent x-rays taken in April 1973 (reports not of record) and September 1976, were interpreted as revealing no degenerative changes or other abnormalities of the thoracic or lumbar spine. In a VA examination dated in June 1988, x-rays were interpreted to reveal mild degenerative changes of the thoracic spine and no abnormalities of the lumbar spine. In a VA orthopedic outpatient treatment record dated in April 1988, it was noted that x-rays taken in February 1988 (reports not of record) revealed decreased L5-S1 space, and the physician diagnosed early degenerative joint disease. However, subsequent x-rays dated in January 1992 were interpreted as negative for fracture, dislocation, bone or joint disease of the lumbar spine, and as revealing osteoarthritic spurs of the thoracic spine. The disability has been variously characterized over the years and is currently characterized as proliferative changes, thoracic and lumbar spine, rated under Diagnostic Codes 5003 and 5292, contemplating arthritis and limitation of motion of the lumbar spine. The Board concludes that in light of the varied findings in the medical evidence in the file, particularly as noted above, separate evaluations are in order for a disability of the thoracic spine and for a disability of the lumbar spine. It is also noted that during his personal hearing dated in December 1991, the veteran made reference to treatment for his back disability. It does not appear that the records have been requested by the RO. Although the file does contain results of nerve conduction studies and an electromyogram dated in October 1990, and spinal x-ray results dated in January 1992, the last VA orthopedic outpatient treatment record in the file is dated in August 1988. Treatment records referred to by the veteran would be useful in order for a fair determination of his claim. Accordingly, the case is being REMANDED for the following action: 1. The RO should obtain all VA outpatient and inpatient records developed since 1988, and should associate them with the file. 2. The veteran should be afforded a VA psychiatric evaluation in order to determine the present nature and extent of his post-traumatic stress disorder. The claims folder should be made available to the examiner prior to the examination for review of the pertinent medical history. The examiner should specifically follow the provisions in the Diagnostic and Statistical Manual of Mental Disorders, (3rd ed., 1987), regarding ratings from the Global Assessment of Functioning Scale (GAF) and the Axis ratings regarding diagnoses and the severity of psychosocial stressors. 3. The RO should adjudicate the matter of assigning separate ratings for a disability of the thoracic spine and the lumbar spine. Any development deemed necessary to this procedure should be accomplished, to include a VA orthopedic examination. It is noted, in this regard, that the veteran was last afforded an examination in January 1992. When the above development has been completed, the case should again be reviewed by the originating agency. If the decision remains adverse to the veteran, he and his representative should be issued a Supplemental Statement of the Case and should be afforded a reasonable period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain clarifying information and no inference should be drawn from it regarding the final disposition of the claim. JEFF MARTIN 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).