Case A26040199

JENNA BRANT · 2026 · Case ID: A26040199

DENIED

Summary

The veteran, who served from November 1993 to November 1994, appeals the denial of service connection for lumbar spine and cervical spine disabilities, as well as a total disability rating based on individual unemployability (TDIU). The veteran claims his lumbar and cervical spine conditions resulted from an in-service injury in July 1994, where he experienced back pain after unloading a heavy toolbox. He reported ongoing back pain throughout the remainder of his service and sought VA treatment post-service. Service treatment records (STRs) documented treatment for back pain assessed as acute muscle strain in July 1994, with normal findings at enlistment and separation examinations, though the separation report noted recurrent back pain. Post-service, a private physician in March 2010 opined the spine damage was likely due to the in-service injury, but this opinion lacked detailed rationale and was considered speculative by the Board. Multiple VA examinations from 2015, 2017, and 2020 consistently opined that the lumbar and cervical spine disabilities were less likely than not related to service, citing the lack of chronicity of care post-service, the transitory nature of the in-service strain, and age-related degenerative changes as the likely cause. The Board found the November 2020 VA opinion most probative due to its clarity, unequivocal nature, and basis in the evidence. The veteran's lay testimony, while consistent, was not given greater weight as it lacked specialized knowledge of etiology. As the evidence preponderated against service connection, the claims for lumbar and cervical spine disabilities were denied. Consequently, the TDIU claim was also denied, as the veteran has no service-connected disabilities.

Special Benefit

TDIU

Docket No.

210609-165093

Full Decision Text

Citation Nr: A26040199
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 210609-165093
DATE: April 29, 2026

ORDER

Service connection for a lumbar spine disability is denied.

Service connection for a cervical spine disability is denied.

A total disability rating based on individual unemployability (TDIU) is denied.

FINDINGS OF FACT

1. The Veteran's lumbar spine and cervical spine disabilities did not have their onset during service and are not otherwise related.

2. The Veteran does not have any service-connected disabilities in order to warrant entitlement to a TDIU rating.

CONCLUSIONS OF LAW

1. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1110, 1155; 38 C.F.R. § 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1993 to November 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

Following the April 2021 decision, the Veteran filed a June 2021 VA Form 10182, Notice of Disagreement (NOD) and the Hearing docket was elected. 38 C.F.R. § 19.2(d). In November 2021, the Veteran testified at a Board hearing.

Procedurally, the three present claims were previously denied in a Board decision dated November 2018, and the decision was not appealed. Thereafter, the Veteran filed a February 2020 Supplemental Claim, and a November 2020 rating decision denied the claims. The Veteran subsequently filed a January 2021 VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), in which he requested review of the prior decision. In April 2021, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal. As noted, the Veteran then filed a June 2021 VA Form 10182.

Therefore, the Board may only consider the evidence of record at the time of the November 2020 rating decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative within 90 days following the hearing. 38 C.F.R. § 20.302. If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Lastly, the Board notes the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, in February 2020, and requested readjudication of the issues, addressed previously by the Board in November 2018. The Board notes in the November 2020 decision, the RO found that new and relevant evidence had been received for the claims, and they were reconsidered and denied based on the evidence of record at the time of that decision. This is a favorable finding the Board will not disturb. Accordingly, the Board does not need to readdress whether new and relevant evidence has been received to reconsider the three claims. 38 C.F.R. § 3.104(c).

Service connection for a lumbar spine disability.

Service connection for a cervical spine disability.

Legal Criteria

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R.
0 decision, the RO found that new and relevant evidence had been received for the claims, and they were reconsidered and denied based on the evidence of record at the time of that decision. This is a favorable finding the Board will not disturb. Accordingly, the Board does not need to readdress whether new and relevant evidence has been received to reconsider the three claims. 38 C.F.R. § 3.104(c).

Service connection for a lumbar spine disability.

Service connection for a cervical spine disability.

Legal Criteria

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776, 778 (Fed. Cir. 2021).

Facts

The Veteran contends that his lumbar and cervical spine disabilities are the result of an in-service injury when he was ordered to unload a vehicle. The Veteran asserted at the November 2021 Board hearing that he was lifting a 300-plus pound toolbox out of a truck when his back gave out, and he experienced severe pain before falling to the ground. He reported that he was sent to the hospital and discharged the same day for a back injury. He reports that he has experienced ongoing back pain throughout the rest of service. He further asserted at the hearing that he remained on a physical profile following the July 1994 injury until his separation from service. He stated following service he attempted to obtain VA treatment for his back, including in 1995, but was unsuccessful.

The Veteran's service treatment records (STRs) show in-service treatment for back pain. At his enlistment, the October 1993 examination documented a normal spine and musculoskeletal system. The Veteran also denied any relevant symptoms upon enlistment. In July 1994, the Veteran received treatment for an injured back, to include service records which document treatment for back pain, assessed as acute muscle strain. The Board notes treatment records near the end of the Veteran's service period did not document the Veteran's reported injury or back treatment, and relevant hospital records are not available after VA took appropriate steps to obtain them. At the Veteran's September 1994 separation examination, the examiner documented a normal spine and musculoskeletal system. However, in the report of medical history at separation, the Veteran noted recurrent back pain.

The relevant post-service evidence includes a September 2008 medical record from the Veteran's attending physician in which he indicated the Veteran has bulging discs and nerve impingement in his spine and he is unable to work and considered disabled. A February 2009 medical record noted the Veteran has severe degenerative disc disease (DDD) of the spine. Further, the physician indicated in March 2010 that due to the Veteran's back disability, he is unable to work and severely restricted in his range of motion. He opined the damage to the Veteran's spine could very likely be the result of a traumatic injury he sustained while in service.

The Veteran was afforded a July 2015 VA examination in which the examiner opined that the Veteran's cervical spine disability was less likely than not related to his active service, as there were no relevant notations in his STRs associated with his spine. The examiner similarly opined that the Veteran's lumbar spine disabilitywas less likely than not related to his active service, to include in-service complaints of back pain.

In a January 2017 VA opinion, the examiner indicated the Veteran's cervical spine disability was less likely than not related to his active service. The examiner cited the STRs, the Veteran's lay statements, and that the initial complaints of neck pain were not until 2009. With regard to the lumbar spine, the January 2017 examiner opined that it was less likely than not related
the Veteran's cervical spine disability was less likely than not related to his active service, as there were no relevant notations in his STRs associated with his spine. The examiner similarly opined that the Veteran's lumbar spine disabilitywas less likely than not related to his active service, to include in-service complaints of back pain.

In a January 2017 VA opinion, the examiner indicated the Veteran's cervical spine disability was less likely than not related to his active service. The examiner cited the STRs, the Veteran's lay statements, and that the initial complaints of neck pain were not until 2009. With regard to the lumbar spine, the January 2017 examiner opined that it was less likely than not related to the Veteran's active service. The examiner explained that documented in-service complaints were related to a muscle strain, which was acute and transitory, and that the Veteran's separation examination documented a normal spine. The examiner acknowledged the Veteran's report of back pain at separation but noted that a 2008 spine x-ray was normal and a concurrent MRI showed small central-disc protrusion. The examiner indicated that it was unlikely that such a spine disability occurred 14 years prior, while the Veteran was in service.

The Veteran was afforded a September 2018 VA examination in which the examiner indicated the Veteran's cervical spine disability is less likely than not related to his active service. The examiner explained that medical literature does not support a correlation between in-service back pain and the Veteran's current neck disabilities. For the lumbar spine disability, the September 2018 examiner similarly concluded that the Veteran's lumbar spine disability is less likely than not related to active service. The examiner again cited the STRs, and acknowledged the Veteran's reported back injury form service, but opined that the first documented complaint of subsequent back pain was not until 2008, and thus, the back disability is not causally related to service.

Along with the Veteran's February 2020 Supplemental Claim, he submitted a buddy statement from a soldier who served with him. The author of the statement reported he served with the Veteran in the motor pool and that he remembers the Veteran going to the doctor on a weekly basis for medical treatment.

Following the February 2020 Supplemental Claim, the Veteran was afforded a VA examination in November 2020 in which the examiner opined the Veteran's back and cervical spine disabilities are not causally related to service. With regard to the Veteran's back, she noted the Veteran experienced back pain and received treatment for such several times in July 1994, and that he was diagnosed with muscle strain and acute back pain. Further, at his separation from service, she noted the Veteran reported recurrent back pain. The examiner indicated there are no STRs which show an in-service traumatic injury and additionally, the Veteran did not receive treatment for his back from 1994 to 2008, which shows no support for any continuity of care. The examiner opined the Veteran's diagnosed DDD of the lumbar spine and intervertebral disc displacement commonly occurs due to age-related wear-and-tear on a spinal disc and may be accelerated by injury, health, and lifestyle factors. She noted DDD of the spine rarely starts from a major traumatic incident. The examiner concluded given the information reviewed and her clinical examination and findings, the Veteran's diagnosed DDD of the lumbar spine with herniated nucleus pulposus is less likely than not incurred in or caused by service, including the noted in-service complaints of back pain.

The November 2020 VA examiner provided similar conclusions for the Veteran's cervical spine disability. She opined while the Veteran experienced back pain and sought treatment for such in service, he is diagnosed with cervical degenerative disc disease, intervertebral disc displacement, stenosis and radiculopathy. She noted degeneration of the spine is not associated with a major traumatic event and is more likely related to age-related wear-and-tear. She reported given the information reviewed and her clinical examination and findings, the Veteran's cervical spine disability is less likely than not incurred in or caused by service, including the noted complaints of in-service back pain.

Analysis

After a careful review of the evidence, the Board finds that the evidence is persuasively against the claims of service connection for lumbar spine and cervical spine disabilities. The Board determines the most probative evidence of record supports that the Veteran's back and cervical disabilities are not related to service, to include his in-service back pain and treatment. Thus, the two service connection claims are denied.

Analysis

The Board affords the most probative weight to the November 2020 VA examination report in which the examiner opined that the Veteran's current back and neck disabilities are not causally related to service, and a nexus has not been established. As discussed, the examiner took note of the Veteran's in-service treatment, as well as the lack of treatment related to his back and cervical spine following service, until 2008. She found there was no chronicity of care for the two disorders, and a nexus has not been established for the claims. The Board finds the November 2020 examiner's opinion is clear and unequivocal and based on the relevant evidence, including the Veteran's STRs and post-service medical evidence. Moreover, the author's rationale is logical and consistent with the facts and information given and is found to be highly probative. See Monzingo v. Shinseki, 26 Vet. App. 97, 105- 06 (2012); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions").

The Board acknowledges the March 2010 private medical opinion in support, in which the Veteran's attending physician provided a positive nexus opinion. As noted, he stated the Veteran's "damage to his spine could very well likely be the result of a traumatic injury sustained while in the armed services in 1994." The Board determines the March 2010 medical opinion is less persuasive than the noted November 2020 VA examination report. The author of the 2010 medical opinion did not provide any explanation or rationale as to how the Veteran's back disability is related to his in-service injury, and there is a lack of discussion of the Veteran's STRs or any other potentially relevant medical or lay evidence. The Board determines the March 2010 author's conclusion is speculative, as he specifically indicated the damage to the Veteran's spine "could very well likely" be the result of an injury sustained during service. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (stating that "may well be" is speculative language in a medical opinion and cannot support a finding of direct or presumptive service connection); McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006) (stating that a speculative medical opinion as to causation cannot establish a medical nexus to service); Bloom v. West, 12 Vet. App. 185, 187 (1999) (use of the term "could," without other rationale or supporting data, is too speculative to support award of benefits). In contrast, as discussed above, the November 2020 VA opinion is found to be clear and unequivocal and based on the relevant evidence, and accordingly, is afforded significant probative weight.

The Board further acknowledges the Veteran's lay statements in support, to include the testimony provided at the November 2021 Board hearing. While such lay evidence provided by the Veteran is thorough and highly consistent, as a lay person, the Veteran has not been shown to have specialized training sufficient to render an opinion as to the etiology of his lumbar spine and cervical spine disabilities. Such issues are complex medical questions which fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Therefore, the Board accords greater probative weight to the November 2020 VA opinion than to the Veteran's lay statements.

Accordingly, the Board determines the evidence of record is persuasively against the claims. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for lumbar spine and cervical spine disabilities is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

TDIU.

Legal Criteria

Total disability ratings for compensation may be assigned when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16
ative weight to the November 2020 VA opinion than to the Veteran's lay statements.

TDIU.

Legal Criteria

In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to:

"The veteran's history, education, skill, and training;

"Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and

"Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity.

Ray v. Wilkie, 31 Vet. App. 58, 73 (2019).

Analysis

The Veteran contends that a TDIU is warranted. In the March 2009 TDIU application, he asserts that his back disability prevents all substantially gainful employment. However, the Veteran has no service-connected disabilities presently and therefore, the claim is denied. As addressed above, the current decision denies service connection for lumbar spine and cervical spine disabilities. As such, the Veteran has no service-connected disabilities to support his claim for a TDIU.

In sum, the Veteran does not have any service-connected disabilities. Since service-connected disability is a basic requirement for a TDIU, there is no legal entitlement to this benefit. Therefore, the claim for a TDIU must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

Jenna Brant

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Isaacs, Brandon

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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