The opinion of the court was delivered by: Marvin Katz, Senior District Judge
Plaintiff brings this action to challenge the denial by the Commissioner of the Social Security Administration of her claim for Disability Insurance Benefits.*fn1
Because the administrative decision is not supported by substantial evidence, the plaintiff Ms. Curry, is entitled to disability benefits.
On April 1, 2000, Ms. Curry was involved in a motor vehicle accident. She immediately felt a "snap" in her cervical spine followed by a burning sensation and a headache. (R. 118, 124). Thereafter, on April 6, 2000, Ms. Curry sought treatment with Dr. Alexander Bunt, Jr. Ms. Curry was suffering from neck and shoulder pain, cervical stiffness and soreness and headache (R. 125). On physical examination, Dr. Bunt found neck pain on passive range of motion (ROM), spasms, and edema in her upper extremities. His diagnosis was cervical strain. He prescribed Motrin and Flexeril and referred her for physical therapy. (R. 123, 126, 130-148).
Ms. Curry continued treatment with Dr. Bunt through May of 2000. His medical records note that she had a herniated disc in her cervical spine, pain on palpation, constant neck pain, muscle spasms, decreased ROM in her cervical spine, and C7 paraspinal tenderness (R. 119-126, 251-252, 254-257). Dr. Bunt referred her to a neurosurgeon, Hagop L. Der Krikorian, J.D. (R. 119-122). Ms. Curry also was treated at the Brookhaven Medical Center for primary care treatment (R. 170-172).
A cervical MRI performed on May 10, 2000 found a moderate to large left extruded disc at C4-5 that touched the spinal cord and central disc protrusions at C5-6 and C6-7 (R. 179, 180, 248). On June 27, 2000 Dr. Der Krikorian examined Ms. Curry and found bilateral diminished reflexes, marked weakness of her left deltoid muscle as well as the right to a lesser extent, and bilateral hyperesthesia in the CS and left C6 distribution. His diagnosis was ruptured extruded moderate to large C4-5 disc herniation, moderate C5 and to a lesser extent C6 radiculopathies (R. 246). A surgical consultation was performed on July 13, 200 (R. 167, 176, 244, 271).
Ms. Curry was admitted to Riddle Memorial Hospital on July 19, 2000 (R. 156-157, 268 270, 274-338). Dr. Der Krikorian performed a cervical micro-discectomy and anterior cervical fusion at C4-5 (R. 163, 164-166). An X-ray taken after surgery documented a slight displaced bone chip at C4-5 (R. 183). Ms. Curry was discharged on July 21, 2000, with a final diagnosis of a herniated disc at C4-5 and bilateral CS radiculopathy with cord compression.
Thereafter, Dr. Der Krikorian continued to treat Ms. Curry. In August 2000, Ms. Curry noted that she had a complete resolution of almost all of her symptoms. (R. 152, 238). Thereafter, Dr. Der Krikorian referred Ms. Curry to Community Rehab Physical Therapy from September through December 2000 (R. 200-203, 204-213, 232, 236-237).
In October of 2000, Ms. Curry complained that the right side of her shoulder and neck had gotten progressively worse. Dr. Der Krikorian recommend a cervical spine MIRI (R. 155, 233). On October 14, 2000, the cervical MRI documented a post anterior fusion at C4-5, progression of the central herniation at CS-6 now touching the spinal cord and a slight progression of the central disc bulge at the C6-7 level (R. 230, 356-357).
In November, 2000, Ms. Curry was suffering from neck pain that radiated to her shoulders and arms, weakness in her left forearm and shoulder, and an inability to elevate her right arm above her shoulder. On physical examination, Dr. Der Krikorian found diminished right brachioradialis and left triceps muscles, weakness of the extensors of the wrist on the left side, mild weakness in the left triceps and mild hyperesthesia in the C7-8 distribution on the left side. Dr. Der Krikorian also reviewed her MIRI and found a progression to the cental herniations at CS 6 and C6-7 with early radiculopathies bilaterally but worse on the left. He recommended further testing and physical therapy (R. 153-154, 224-225). A November 9, 2000, a MIRI of Ms. Curry's right shoulder documented prominent partial thickness tear of the rotator cuff tendon. (R. 158 159).
In December of 2000, Ms. Curry explained that her symptoms had remained the same. Dr. Der Krikorian noted that her Doppler study was suspicious for thoracic outlet syndrome. He referred her to an orthopedic surgeon for her shoulder (R. 151, 223).
On December 18, 2000, Ms. Curry sought treatment with orthopedic surgeon, Vincent DiStefano, M.D. She explained that she had been involved in a motor vehicle accident and since then had suffered from neck and shoulder pain. In addition, she expounded that her pain kept her from sleeping, that she could not raise her arm above her head, and had difficulty reaching. On physical examination, Dr. DiStefano found slight decreased range of motion in her neck; that she had tenderness in her acromioclavicular joint, biceps and entire rotator cuff; that she had positive Speed, Yergason, and O'Brien tests; and significant pain with cross-arm adduction. His ...