United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY COLE, District Judge.
Maria Sepeda seeks review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration ("Agency") denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"). 42 U.S.C. §§ 423(d)(2). Ms. Sepeda asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.
Ms. Sepeda applied for DIB on August 1, 2008, alleging that she had become disabled on May 30, 2008, due to a cervical spinal injury, numbness and weakness in her left leg, and numbness in her right arm. (Administrative Record ("R.") 133-39, ). Her application was denied initially and upon reconsideration (R. 84-91, 93-95). Ms. Sepeda filed a timely request for a hearing. An administrative law judge ("ALJ") convened a hearing at which Ms. Sepeda, represented by counsel, appeared and testified. In addition, Thomas Gusloff testified as a vocational expert. (R. 43-83). On June 4, 2010, the ALJ issued a decision finding that Ms. Sepeda was not disabled because she could perform light work that did not involve climbing ladders, ropes, or scaffolds, or more than occasional climbing of ramps/stairs, balancing, stooping, crouching, kneeling or crawling, and was limited to simple, routine and repetitive tasks. (R. 16-34). The ALJ's decision then became the final decision of the Commissioner when the Appeals Council denied Ms. Sepeda's request for review. (R. 1-4). See 20 C.F.R. §§ 404.955; 404.981. Ms. Sepeda has appealed that decision to the federal district court under 42 U.S.C. § 405(g), and the parties have consented to the jurisdiction of a magistrate judge pursuant to 28 U.S.C. § 636(c).
THE EVIDENCE OF RECORD
The Vocational Evidence
Ms. Sepeda was born on November 26, 1966, making her forty-three years old at the time of the ALJ's decision. (R. 158). She is 5'2" tall and weighs 217 pounds. (R. 162). She has a high school education. (R. 169). She has worked a number of jobs, including packing and assembly jobs in warehouses and factories. Most recently, she has worked as a custodian at a church. (R. 164).
The Medical Evidence
An April 14, 2008 MRI of the lumbar spine showed a tiny disc herniation with annular tear at the L5-S1 level. (R. 313). On May 15, 2008, an MRI of the thoracic spine was normal. (R. 309). The MRI of the cervical spine, however, revealed degenerative changes with disc bulging and osteophytes at C5-6 and C6-7. There was also flattening of the spinal cord at C5-6, and foraminal narrowing at C6-7 due to disc protrusion. (R. 311). On June 8, 2008, an MRI of the lumbar spine showed a very small disc protrusion or bony osteophyte at T7-8. (R. 306).
On June 23, 2008, it was determined that Ms. Sepeda would require a cervical discectomy and fusion at C5-6, C6-7. (R. 295-96, 318). She had upgoing toes on the right side, strength decreased to 4-/5 on the left side, and some spasticity of the neck. (R. 318). A hard cervical collar was prescribed with use after the operation. (R. 297). Post-operatively, a CT scan revealed that the stabilizing plate was separated from the vertebral body by 3 mm at C5-6, but that hardware was otherwise in a good position. (R. 299). Elsewhere, there were no more than mild degenerative changes. (R. 299).
Ms. Sepeda called her doctor on August 5, 2008, to complain of intermittent low back pain and a feeling of weakness in her left leg. She had no numbness or tingling. (R. 368). On August 13, 2008, an MRI of the lumbar spine revealed a small lesion at the L5 level and a protruding disc at the L5-S1 level, with mild indenting of the dural sac. (R. 300-301). A subsequent CT scan essentially echoed these findings. (R. 303). A thoracic spine MRI on August 23rd revealed mild degenerative changes and mild to moderate foraminal narrowing at T9-10. (R. 320).
On September 26, 2008, Dr. Richard Bilinsky reviewed the medical evidence on behalf of the disability agency. (R. 331-38). He concluded that Ms. Sepeda would be able to perform light work except for more than occasional climbing of ladders/ropes/scaffolds, stooping, or crawling. (R. 333). Her ability to constantly reach overhead was also limited. (R. 334).
On September 29, 2008, Ms. Sepeda reported left leg weakness and numbness. Sensation and strength were within normal limits. (R. 369). On October 20, 2008, Ms. Sepeda went to a pain treatment center, complaining of low back pain radiating to both legs and left leg weakness. (R. 342). The pain was 10/10. (R. 342). Examination revealed left leg strength reduced to 3/5, diminished reflexes, and significantly decreased left lumbar range of motion. (R. 342). She was given an epidural steroid injection the next day. (R. 343).
On November 14, 2008, Ms. Sepeda underwent an EMG and nerve conduction study to rule out generalized neuropathy and lumbosacral radiculopathy. The study was essentially normal. There was no evidence of any chronic lumbosacral radiculopathy in either leg, no evidence of generalized radiculopathy, and no evidence of myopathy. (R. 357). Ms. Sepeda received another epidural steroid injection on December 1, 2008. (R. 350).
On January 20, 2009, Dr. Solfia Saulog reviewed the medical record on behalf of the disability agency and agreed with Dr. Bilinsky's findings of September 26, 2008. (R. 373). On February 23, 2009, Ms. Sepeda had a thoracic epidural steroid injection. (R. 380). On March 23, 2009, Ms. Sepeda complained of constant thoracic pain. She rated it a 10 on a scale of 1 to 10, and said the intensity varied. (R. 378). She complained of thoracic and lower back pain with left leg weakness on May 8, 2009, rating it a 6-7 and again, saying that it varied in intensity. (R. 377). She had essentially the same complaints on July 23, 2009, but did not rate her pain's intensity. (R. 376). On June 1, 2009, Ms. Sepeda complained of moderate back pain - rating it a 6 - that, oddly, she said had began only recently. (R. 428). Glucose was again elevated at 150 (R. 433), but there were no diabetic symptoms - thirst, sweating, etc. (R. 429). Musculoskeletal exam revealed moderately reduced lumbar extension and lateral motion. Strength, tone, and stability were normal. (R. 430).
On July 16, 2009, Ms. Sepeda's back was fine - she had no complaints. (R. 440). She had no diabetic symptoms. Diabetes was non-insulin dependent and controlled. (R. 441). On September 3, 2009, Ms. Sepeda's glucose was elevated at 150. (R. 410). She again had no complaints on October 15, 2009. (R. 446-47). On November 14, 2009, glucose was normal. (R. 452). Ms. Sepeda began to experience foot and ankle symptoms on November 18th that she described as moderate "burning, cramping, sharp, shooting." (R. 454). Musculoskeletal exam was normal - gait was smooth, range of motion was full. (R. 454). Diabetes was improved. (R. 455).
On December 11, 2009, Ms. Sepeda complained of thoracic and low back pain with some pain and tingling in both legs. She rated it an 8, but it sometimes got down to a 5. (R. 393). Exam was normal except for some tenderness in the feet. (R. 393-94). It was noted that "diabetic neuropathy is making huge part of a problem for this pt." (R. 394).
On January 8, 2010, Ms. Sepeda complained of back pain she claimed "began months ago." It radiated to the right leg and she rated it a 5 out of 10. She continued to have the foot symptoms she reported in November 2009. (R. 454). Musculoskeletal exam was normal - gait was smooth, there was no tenderness in the lower extremities and strength and range of motion was normal. (R. 455). There was moderately reduced lateral motion and flexion, however. (R. 461-62).
An MRI on February 22, 2010, showed improvement in the lumbar spine with the cystic focus near LR gone and no more than mild diffuse disc bulge at L5-S1 with no significant stenosis of the central canal or neural foramina. (R. 500). On March 5, 2010, Ms. Sepeda went in to see her doctor, who noted she was "using a cane to walk now due to chronic back pain radiating t[o] Lt leg." But musculoskeletal exam revealed no instability or tenderness, and strength and tone were normal. Lateral motion was moderately reduced. (R. 498).
On March 15, 2010, Ms. Sepeda's treating doctor referred her for an orthopedic consult. She was noted to walk with a limp and use a cane. She had a full range of motion in her neck and she was neurologically intact in her upper extremities. There was tenderness between L3 and S1. Strength in the left quadriceps was somewhat diminished at 4/5. She was otherwise neurologically intact in terms of strength and sensation, reflexes were normal on the right but negative on the left. Babinski sign was negative. (R. 504). The doctor reviewed the most recent MRIs, noting that the thoracic study was negative; the lumbar study revealed some degenerative changes between L4 and S1, but no evidence of nerve impingement; the cervical spine show only evidence of the surgical fusion. (R. 505). Dr. Rinella said Ms. Sepeda should be as active as possible and ambulate as much as possible. She should pursue aqua therapy. She should lose weight. These were the only interventions that could predictably improve her symptoms. (R. 505).
The Administrative Hearing ...