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Christian v. Colvin

United States District Court, E.D. Pennsylvania

January 25, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security


          O'NEILL, J.

         Plaintiff 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.


         I. Procedural History

         On June 13, 2012, plaintiff, who was forty-seven years old at the time, [1] protectively applied for Social Security Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI), alleging disability since August 1, 2007. R. 179-191.[2] 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.

         On July 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.

         II. Medical Records[3]

         Plaintiff 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.

         The 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.

         On 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.

         The 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.

         Upon 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. R. 280.

         Plaintiff 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.

         Plaintiff 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.

         Two 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 injections. Id.

         On 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.

         Over 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.

         Plaintiff's 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.

         Plaintiff 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.

         On 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.

         At the 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 Lyrica. Id.

         In a 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.

         On 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.

         On the 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.

         Plaintiff 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. Id.

         On that 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.

         In a 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.

         Plaintiff 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 polyneuropathy. Id.

         The 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. ...

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