United States District Court, N.D. Illinois, Eastern Division
CURTIS E. PEARSON, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
Curtis E. Pearson seeks reversal and remand of a determination by the Commissioner of Social Security, Carolyn W. Colvin ("Commissioner"), denying him Disability Insurance Benefits ("DIB") from October 22, 2004 to February 25, 2009 (doc. # 19). The Commissioner has filed a motion seeking summary affirmance of the decision denying benefits (doc. # 26). For the following reasons, the Court grants Mr. Pearson's motion for remand and denies the Commissioner's motion to affirm.
On July 30, 2008, when he was 44 years old, Mr. Pearson filed his application for DIB, alleging that he became disabled on October 22, 2004 due to a back injury (R. 103). His claim was denied initially and upon reconsideration; thereafter, on November 17, 2010, an Administrative Law Judge ("ALJ") held a hearing (R. 15). On December 8, 2010, the ALJ issued a written opinion concluding that Mr. Pearson was disabled from February 26, 2009 through September 30, 2011, his date late insured, but that Mr. Pearson was not disabled or entitled to benefits prior to February 26, 2009 (R. 26).
Prior to his alleged onset date, Mr. Pearson worked primarily as a sales engineer, selling IT services and designing data networks for business units (R. 39, 42). On October 22, 2004, he stooped under his desk at work to plug in his laptop and hit his back (R. 44-45). Afterward, he felt a burning, aching, stabbing pain in his groin, legs, and lower back (R. 44, 350). Mr. Pearson returned to work only briefly after the accident (R. 39-41, 80).
A November 1, 2004 MRI revealed a herniated disc at L4-L5 on the right side, and on November 8, 2004, Mr. Pearson visited a pain clinic complaining of severe back pain on his right side (R. 804, 808). Dr. Giri Gireesan, M.D., observed that while his gait was normal and he had 5/5 strength in his extremities, Mr. Pearson had increased pain in the back area with flexion, extension, and lateral rotations (R. 808). Dr. Gireesan recommended that Mr. Pearson undergo a course of three epidural steroid injections to try to alleviate his pain ( Id. ). Dr. Rom Stevens performed three injections over three weeks, and reported that Mr. Pearson had 50 to 80 percent pain relief (R. 855-57).
Mr. Pearson reported to Dr. Gireesan, however, that the injections did not provide significant pain relief, and Mr. Pearson requested surgery (R. 843). Dr. Gireesan ordered a follow-up MRI on December 3, 2004, which showed a bulging, not herniated disc (R. 842). Dr. Gireesan recommended physical therapy instead of back surgery, and advised Mr. Pearson's primary care physician that Mr. Pearson may require a medical workup to determine other possible causes for his pain ( Id. ). Mr. Pearson attended physical therapy and took anti-inflammatories and muscle relaxers, but his severe back pain continued (R. 45, 841).
On December 16, 2004, Mr. Pearson visited a hematologist, Dr. Anaadriana Zakarija, to evaluate the effects that back surgery would have on his sickle cell disease (diagnosed in 1987) (R. 427). Dr. Zakarija warned that back surgery could result in the development of sickle cell crises (R. 429).
On February 24, 2005, Dr. Matthew Hepler, an orthopedic surgeon, examined Mr. Pearson for the first time. Mr. Pearson described having an aching, stabbing pain, rated at 10/10, across his lower back and radiating down both legs (R. 440). The pain continued without relief despite a wide range of non-operative treatment, including injections, anti-inflammatories, pain medications, and physical therapy ( Id. ). Dr. Hepler noted that Mr. Pearson had decreased range of motion and pain on flexion in his spine, and straight leg raises were positive for pain (R. 441). Dr. Hepler diagnosed him with L4-5 disc herniation and right L4-5 radicular pain (R. 441-42).
After discussing with Dr. Zakarija the risks that surgery posed due to Mr. Pearson's sickle cell trait, Dr. Hepler and Mr. Pearson decided to proceed with surgical treatment since the non-surgical treatments had not provided Mr. Pearson with lasting pain relief (R. 496). On March 31, 2005, Dr. Hepler performed a microdiskectomy on Mr. Pearson, which removed the damaged portion of his herniated disk (R. 495-97). At a post-operative visit on April 15, 2005, while still on Norco, Mr. Pearson told Dr. Hepler that his groin pain was much better and his right leg pain was about 25 percent better, but he was still experiencing pain in his right calf and foot (R. 341). By May 16, 2005, Mr. Pearson stated that his groin pain was essentially gone and his leg pain was 20 percent better than before surgery (R. 338). At that time, he was still taking Norco, Ultram, and Neurontin for pain ( Id. ).
On May 27, 2005, Mr. Pearson was admitted to the hospital for vomiting blood and blood in his stool (R. 504). On June 16, 2005, Mr. Pearson followed up with Dr. Zakarija, complaining of abdominal pain, intermittent night sweats and headaches, and an elevated white blood cell count (R. 416). Dr. Zakarija noted that "most concerning" was Mr. Pearson's abdominal pain and "tender hepatosplenomegaly, " or enlarged liver and spleen (R. 417). See http://www.nlm.nih.gov/medlineplus/ency/article/003275.htm.
Mr. Pearson saw Dr. Hepler again on July 8, 2005. He told Dr. Hepler that his leg symptoms were essentially resolved, but he still had pain in his buttock and back, which was aggravated with activity (R. 335). There were "no big changes" at his next appointment with Dr. Hepler, on September 7, 2005 (R. 332-34).
On October 5, 2005, however, Mr. Pearson reported to Dr. Hepler that in the last few weeks there had been a flare-up of his pain: his right back pain was radiating into his right groin, which was aggravated by bending and twisting (R. 330). Dr. Hepler's physical examination revealed that Mr. Pearson had decreased ...