United States District Court, E.D. Pennsylvania
SHIRLEY A. CHRISTIAN
CAROLYN W. COLVIN, Acting Commissioner of Social Security
Shirley A. Christian brings the present action to challenge
the decision by defendant Commissioner of Social Security
rejecting her applications for Disability Insurance Benefit
and Supplemental Security Income under Titles II and XVI
respectively of the Social Security Act, 42 U.S.C. §
401, et seq. Upon review of the record, I find that
plaintiff's request for review should be denied and the
Commissioner's finding of disability should be affirmed.
13, 2012, plaintiff, who was forty-seven years old at the
time,  protectively applied for Social Security
Disability Insurance Benefits (DIB) and Supplemental Security
Income (SSI), alleging disability since August 1, 2007. R.
179-191. Following the state agency's denial of
her applications on August 29, 2012, plaintiff requested
administrative review. R. 119-131. Administrative Law Judge
(ALJ) Daniel Myers held an administrative hearing on December
31, 2013, at which time plaintiff and a vocational expert
testified. R. 27- 80. On March 6, 2014, ALJ Myers issued a
decision noting that, based on plaintiff's earnings
records, plaintiff had to establish a disability on or before
September 30, 2012 in order to be entitled to a period of
disability and disability insurance benefits. (R. 17.) He
determined that plaintiff had the “severe”
impairments of degenerative disc disease of the lumbar spine,
depression and anxiety which rendered her unable to return to
her past relevant work. R. 17-26. In light of the vocational
expert's testimony, however, the ALJ found plaintiff
capable of performing other jobs existing in significant
numbers in the national economy and, therefore, deemed her
not “disabled” for purposes of her benefits
applications. Id. Plaintiff then appealed this
decision to the Appeals Council, which denied review on May
7, 2015. R. 1-4.
7, 2015, plaintiff initiated the current action seeking
review of the Commissioner's final decision. She filed
her brief in support of her request for review on October 23,
2015, and defendant Commissioner of Social Security responded
on November 24, 2015.
contends that her disability began on August 1, 2007. R. 185.
The earliest medical notations from 2007-2009 indicate that
she primarily sought medical care for various ailments,
including depression and anxiety, from Dr. Timothy Quinn of
Lancaster Family Associates. R. 617-22. Notes from Lancaster
Family Associates throughout 2009 revealed that plaintiff
still suffered from anxiety and depression and was taking
Lexapro, but examinations were relatively unremarkable. R.
608-610. In December 2009, plaintiff went to the Lancaster
General Hospital emergency room with complaints of a panic
attack. R. 303, 407-09. Studies were normal and plaintiff
improved during observation. R. 304. She was discharged with
a diagnosis of anxiety and chest pain. R. 307.
medical record reflects additional visits to her primary care
physician throughout 2010, few of which were related to her
present impairments. In August 2010, plaintiff complained of
fatigue, headaches and anxiety, and the doctor noted her
chronic problems of depressive disorder and anxiety. R. 734.
In a subsequent visit of September 28, 2010, plaintiff
reported improvement in her anxiety. R. 731. Although she
continued to suffer anxious and fearful thoughts, she stated
that “it is not difficult at all to meet home, work, or
social obligations.” Id.
October 29, 2010, after experiencing a week of low back pain,
plaintiff first met with John A. Gastaldo, M.D. of
Neuroscience & Spine Associates. R. 509. Dr.
Gastaldo's notes echoed plaintiff's reports that she
had had three prior lumbar laminectomies, the last of which
was more than ten years ago, and had been pain free until the
previous week. Id. On examination, plaintiff's
gait, station and muscle strength were normal in both her
upper and lower extremities. Id. Dr. Gastaldo opined
that plaintiff had “acute lumbar strain superimposed
upon lumbar degenerative disc disease.” R. 510. He
referred her for two weeks of physical therapy, which he
expected to dramatically improve her symptoms. Id.
record is again relatively sparse until April 8, 2011, when
plaintiff returned to Neuroscience & Spine Associates
with new complaints of low back pain that had started two
months earlier. R. 505, 331. Plaintiff indicated to Sandra L.
Moffett, P.A.-C that she never attended the prescribed
physical therapy and she continued to have pain in her low
back, radiating toward the right lower extremity. R. 505. She
explained that she treated with Aleve, ibuprofen and Tylenol,
especially when babysitting small children in her home. R.
505. Examination was relatively unremarkable with good range
of motion, normal gait, full motor strength and mildly
diminished sensation. R. 505. On P.A. Moffett's referral,
plaintiff underwent an MRI of her lumbar spine. R. 331. The
results revealed mild stable dextroscoliotic curvature of the
lumbar spine and slight progression of degenerative changes
at the L4 through S1. R. 418.
referral from her doctor, plaintiff attended an initial
evaluation at Lancaster General Physical Medicine &
Rehabilitation on April 12, 2011, where she again reported
the onset date of her pain as two months prior. R. 291.
Although therapy was prescribed three times a week for twelve
visits in order to reduce her pain and increase her
functionality, r. 290, 503, plaintiff attended only five
therapy sessions and then skipped her next three
appointments. R. 280, 285-90. On May 6, 2011, plaintiff
indicated that that she wanted to remain “on
hold” until her next doctor's appointment because
she felt the exercises were only giving her temporary relief.
had a second MRI on April 20, 2011, which showed degenerative
and postoperative changes on the right at ¶ 4-L5 where
there was some right lateral recess stenosis. R. 315. During
her May 9, 2011 follow up with Dr. Gastaldo, her neurological
examination was entirely normal, but her sensory examination
showed mildly diminished sensation in the lateral aspect of
her right leg. R. 499. In addition, she had mild tenderness
to palpation to the right of the midline in the lumbar area.
R. 499. Otherwise, motor examination showed no abnormalities,
she had normal muscle tone with no atrophy, strength was 5/5
bilaterally in both upper in lower extremities and her
reflexes were 2/2. R. 500. Plaintiff's gait was sturdy
and symmetric. R. 500. Dr. Gastaldo remarked that the MRI
showed some degenerative disc disease at the L4-L5 and L5-S1
levels with a small disc herniation at the L5-S1 level, but
no neural foraminal stenosis. R. 500.
underwent several radiographic tests on May 23, 2011. R. 336.
An X-ray of her lumbar spine revealed severe discogenic
disease and degenerative spondylitic change at ¶ 4-L5
and L5-S1, mild anterolisthesis of L4 with respect to L5 and
retrolisthesis of L5 with respect to S1 and mild scoliosis,
but no significant change from the previous April 2011
examination. R. 337. Similarly, a bone scan showed discogenic
disease and degenerative spondylitic change in the L4-L5 and
L5-S1 interspaces, degenerative or arthritic change in the
left L4-L5 facet and mild degenerative changes in the lower
thoracic spine at ¶ 9-T10. R. 340.
days later, plaintiff underwent a lumbar myelogram which
showed mild to moderate canal narrowing at ¶ 4-L5 with
significant disc space narrowing at ¶ 4-L5 and L5-S1. R.
342. A CT myelogram of the lumbar spine revealed degenerative
changes, mainly at ¶ 4-L5 and L5-S1 with postoperative
changes, scar tissue to the right of the midline at ¶
4-L5 and a small central herniation at ¶ 5-S1. R. 344.
Based on these studies, Dr. Gastaldo opined that plaintiff
had “at best, mild stenosis, which may be composed of
scar tissue at ¶ 4-L5 on the right.” R. 490. He
noted subtle changes at ¶ 5-S1 as well, but no obvious
root compromise. Id. He recommended epidural
referral from Dr. Gastaldo, plaintiff went to the Pain Center
where she was treated by Cora Bilger, P.A.-C. and Dr.
Monteforte. Plaintiff described sharp, stabbing, shooting
pain in her right buttocks and right posterior thigh to the
knee with chronic numbness and tingling in her lateral calf.
R. 487. She rated her pain as a four out of ten and said
that, occasionally, the pain makes her feel depressed.
Id. Musculoskeletal examination revealed that she
had normal gait and station, was brisk getting in and out of
the chair and on and off the table without assistance, had
full lumbar range of motion, was nontender over lower lumbar
facets, but was tender over the right sacroiliac joint with a
positive Patrick's maneuver. R. 488. Subsequent to a
sacroiliac injection on June 7, 2011, plaintiff stated that
she felt an overall 70% relief of her symptoms, had no side
effects and was sleeping without difficulty. R. 485.
Examination was normal and plaintiff did not feel the need
for an epidural at the time. The doctor prescribed no
medication. R. 486.
the following few months, plaintiff had only sporadic visits
to her primary care doctor for isolated problems including
insomnia, a persistent cough and congestion, mammogram
prescriptions and a recheck of her anxiety. R. 345, 716, 719,
722. At her October 11, 2011 visit, plaintiff reported that
her anxiety had improved and it was not at all difficult to
meet home, work or social obligations. R. 716. Although she
had continued anxiety symptoms, the doctor opined that her
depression was stable. R. 716-17. At her February 7, 2012
appointment, she had no gait disturbance or psychiatric
symptoms. R. 713.
next documented complaints of low back pain occurred on March
5, 2012 when she returned to her primary care doctor
describing a brand new onset of sharp and stabbing pain
radiating into her right thigh. R. 578. Dr. Quinn remarked
that she had posterior tenderness, paravertebral muscle
spams, right lumbosacral tenderness and a muscle spasm in her
lumbar spine. R. 579. Straight leg raises were positive.
Id. The doctor put her on Naprosyn and Flexeril and
suggested physical therapy, which plaintiff refused.
Id. Two days later, plaintiff went to the emergency
room with complaints of lower back and right leg pain. R.
317-329. Physical examination revealed tenderness in the
right paraspinal muscles of the lumbar spine, but normal
reflexes, sensation and motor function. R. 320. A lumbar CT
scan showed chronic degenerative disc disease at ¶ 4-L5
and a central disc protrusion posteriorly at ¶ 5-S1. R.
321. She was discharged with a prescription for Valium and
hydromorphone and diagnosed with “acute low back pain
improving with narcotic treatment.” Id.
then returned to Dr. Gastaldo on March 12, 2012, who
determined that despite normal reflexes and motor sensory
exam in her right lower extremity, the severity of her
symptoms warranted an MRI and an increase in pain medication.
R. 484. The subsequent MRI revealed some degenerative changes
in the spine itself, but no clear root compromise. R. 482. It
also showed a large right cystic mass in the pelvis.
Id. He did not see an obvious cause for the pain and
swelling in her right lower extremity. Id.
March 21, 2012, plaintiff's pelvic ultrasound showed a
large thin-walled ovarian cyst on the right, which the doctor
believed to be the likely cause of her right leg pain. R.
351. The treating gynecologist recommended surgical removal
of the cyst and plaintiff was transferred to the Women and
Babies Hospital for a hysterectomy. R. 669-70. In her
post-operative visit with her family doctor, she continued to
complain of persistent lower back pain. R. 575. As of her
April 25, 2012 follow-up visit with Dr. Gastaldo, however,
plaintiff stated that her back pain was totally resolved and
the doctor felt no return visit was necessary. R. 481.
end of May 2012, plaintiff first met with James P. Argires,
M.D. regarding her continued right low back and leg pain. R.
563. Plaintiff's neurological examination was
unremarkable as evidenced by negative straight leg raises, no
gross motor or sensory reflex impairment, normal ambulation
and no gross motor or sensory deficit. Id. Dr.
Agires diagnosed her with lumbar radiculopathy most likely
related to intraneural scarring, multilevel lumbar
degenerative diskogenic disease and facet arthropathy
bilateral L4-L5 and L5-S1. R. 564. He ordered a bone scan and
an EMG, but did not recommend surgery. Id. The
subsequent EMG showed a right L5-S1 radiculopathy with
ongoing denervation of the right L5-S1 myotome, but no
evidence of peripheral neuropathy or peroneal neuropathy. R.
567. The bone scan showed evidence consistent with indicated
disc disease. R. 597-98. During a follow-up visit in June
2012, Dr. Argires attributed her leg pain to the ongoing
denervation of the S1 root. R. 569. Although she had negative
straight leg raises and no gross motor or sensory changes,
her reflexes were totally absent in the lower extremities.
Id. He changed her medications to Cymbalta and
July 10, 2012 return visit with Dr. Argires, plaintiff
complained of a continued paresthetic feeling in her right
leg improved somewhat with Lyrica. R. 689. The doctor
increased her dosage and directed her to increase her
physical activities. Id. On physical examination, he
found no gross motor or sensory deficit. Id. During
her September 4, 2012 follow up, plaintiff stated that her
lower back pain was managed well with the Lyrica except for
an occasional flare of symptoms. R. 900. A recent MRI
demonstrated a significant amount of spinal stenosis from
L4-L5 to L5-S1 along with significant facet arthropathy and a
disk spur causing thecal sac and nerve root compression. R.
901. At that time, he opined that plaintiff would consider
surgery in the very near future if she did not see any
further improvement with medication. R. 901-02.
Plaintiff's November 19, 2012 appointment revealed
similar complaints. R. 1491. Although plaintiff demonstrated
markedly diminished reflexes and difficulty ambulating, she
still had negative straight leg raising and no gross motor or
sensory changes. R. 1493.
August 9, 2012, state agency consultant Jay Shaw, M.D.
conducted a review of plaintiff's medical records and
completed a residual functional capacity analysis in
connection with plaintiff's recently-filed application
for benefits. R. 87-91. He opined that plaintiff could
occasionally lift/carry up to twenty pounds in an eight-hour
workday, frequently lift/carry up to ten pounds in an
eight-hour workday, stand/walk and sit about six hours in an
eight-hour workday and had no push/pull or postural
limitations. R. 87. He reasoned that although plaintiff had
back impairments, he believed her complaints of pain to be
out of proportion to the objective findings on imaging
studies and on examination. R. 87-88.
same date, state agency consultant Alex Siegel, Ph.D
conducted a mental residual functional capacity assessment
based on plaintiff's medical records. Dr. Siegel opined
that plaintiff had moderate limitations on her ability to
understand and remember detailed instructions, but otherwise
had no limitations on her sustained concentration and
persistence. R. 88-89. He partially credited her complaints
stemming from her anxiety disorder and depression and
believed her to be limited to work involving one-to-two step
tasks and simple, routine, repetitive work in a stable
environment. R. 89. Based on her activities of daily living,
however, he declined to fully credit her claimed mental
limitations. R. 89-90.
met with Dr. Argires again on January 7, 2013, at which time
he reviewed her recent EMG, which revealed a severe
polymotor, sensory neuropathy superimposed upon rather
radicular changes from the past surgical procedures. R. 1494.
He believed that she was stable on her medications of Soma
and Lyrica, as well as BuSpar for depression, and opined that
no further surgery was necessary. Id. Given the
stability of her condition, he discharged her from treatment
and remarked that he would see her again if anything changed.
same day, Dr. Argiries also completed a spinal impairment
questionnaire for purposes of plaintiff's application for
social security benefits. R. 813. He diagnosed her with
multi-level degenerative disc disease, polymotor sensory
neuropathy and progressive spinal stenosis with a guarded
prognosis. Id. In support of his diagnosis, he noted
that she had limited range of motion in her lumbar region,
lumbar tenderness, muscle spasm, minimal sensory loss,
diminished reflexes and muscle weakness. R. 814. He also
remarked that she had swelling, trigger points, positive
straight leg raises and ambulated with a cane. Id.
He described her pain as intense and constant. R. 815. As to
her work-related capabilities, he opined that she could sit,
stand and walk less than one hour in an eight hour work day,
should not sit continuously and would have to get up and move
around every thirty minutes. R. 816. He further suggested
that she could only occasionally lift objects under five
pounds and occasionally carry objects under ten pounds. R.
816-17. He opined that her impairments were ongoing and would
last at least twelve months and, due to her chronic anxiety,
she was incapable of even low stress jobs. R. 817.
Ultimately, he concluded she was “disabled from any and
all employment due to progressive polymotor sensory
neuropathy.” R. 819.
January 9, 2013 visit with her primary doctor, plaintiff
re-raised complaints of anxiety and depression. R. 924. She
stated that she faced social isolation, aggravated by the
winter season and chronic pain from her back. Id.
Although she had been doing well with Celexa and Buspar, she
had lately been experiencing more mood swings and feeling
more depressed. Id. Her mental status examination
was almost entirely normal. R. 926. The doctor diagnosed her
with depressive disorder and anxiety and recommended a
psychiatric evaluation. Id. After that appointment
she began receiving counseling and, as of her next
appointment with Dr. Quinn, she reported doing well with her
anxiety. R. 928.
returned to Dr. Argires on March 19, 2013 with bilateral leg
discomfort and pain and some difficulty ambulating. R. 1493.
On examination, straight leg raises were negative and she had
no gross motor or sensory changes, but reflexes were markedly
diminished and she had trouble ambulating for any distance.
Id. He made no medication changes and suggested
electrodiagnostic studies to be sure he was not overlooking a
record is devoid of treatment notes until plaintiff's
return to Dr. Argires on September 4, 2013. He believed that
her condition had worsened, noting that she had difficulty
walking for any distances, consistently used a walker,
ambulated in a semiflexed position with a flattened lumbar
lordotic curve and required assistance in rising from a
chair. R. 887. On October 8, 2014, plaintiff met with Dr.
Agires's son, surgeon Dr. Perry Agires. R. 873. He fitted
her for a lumbosacral brace to help stabilize her lumbar
spine. R. 875. Plaintiff also had another MRI which revealed
severe degenerative signal changes at ¶ 4-5 and L5-S1.
R. 876. At ¶ 5-S1, she had central canal stenosis
secondary to a moderately large midline herniated disk at
¶ 4-5 with wide laminectomy defects. R. 876. ...