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Callahan v. Colvin

United States District Court, N.D. Illinois, Eastern Division

October 19, 2016

SHIRLEY GRACE SARAH CALLAHAN, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          Michael T. Mason United States Magistrate Judge.

         Claimant Shirley Callahan (“Callahan” or “Claimant”) seeks judicial review under 42 U.S.C. §405(g) of a final decision of Defendant Commissioner of the Social Security Administration (“SSA”) denying her claim for Social Security Disability Insurance Benefits (“DIB”) benefits under Title II of the Social Security Act (“the Act”). 42 U.S.C. §§416(1); 423. The parties have consented to the jurisdiction of a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Claimant asks that the court reverse the decision of the Commissioner (Dkt. 32) and the Commissioner asks that the decision be affirmed. (Dkt. 42). For the reasons that follow, Claimant's motion is granted and the Commissioner's motion is denied. This case is remanded to the SSA for further proceedings consistent with this opinion.

         I. BACKGROUND

         A. Procedural History

         Claimant applied for DIB on September 11, 2012, alleging that she had been disabled since August 26, 2011, due to back problems. (R. 137-143, 161.) Her application was denied initially and on reconsideration (R. 63-84, 101-103), and she filed a request for an administrative hearing. (R. 104.) On February 5, 2014, an administrative law judge (“ALJ”) convened a hearing at which Claimant testified and was represented by counsel. (R. 37-60.) In addition, Thomas Grzesik testified as a vocational expert (“VE”). (R. 54-59.) On February 27, 2014, the ALJ denied the Claimant's application for DIB, finding that she was not disabled because she was capable of performing unskilled, sedentary jobs that exist in significant numbers in the national economy. (R. 23-32.) This became the final decision of the Commissioner when the Appeals Council denied the Claimant's request for review on May 5, 2015. (R. 1-3.) See 20 C.F.R. §§404.955; 404.981. That decision is now before the District Court for review under 42 U.S.C. §405(g).

         B. Factual Background

         Claimant was born on January 8, 1987 (R. 137), making her twenty-seven years old on the date of the ALJ's decision. She has a high-school education. (R. 43.) Claimant has had a number of jobs since 2008, working seasonally as a landscaper in the good weather and doing snow plowing in the winter. (R. 173.) She's also had a couple of jobs as a cook in a restaurant. (R. 173.) She claims she has been unable to work since she injured her back in a car accident in August of 2011. (R. 293.) Claimant is single, and lives with her parents. (R. 42.)

         C. The Medical Record

         In August 2011, Claimant was involved in a car accident. (R. 293.) Immediately thereafter, she began having severe pain in her back, neck, and left lower extremity. (R. 293.) At first, Claimant sought relief through chiropractic treatments and massage therapy. (R. 293). But, the pain continued to get worse and Claimant subsequently got a referral to see Dr. Tyler Koski at the Neurosurgery Clinic at Northwestern Memorial Hospital on January 6, 2012. (R. 293.) Dr. Koski noted that Claimant had not had injections nor had she done a “more formalized physical therapy regimen.” (R. 293.) During the examination, Dr. Koski reviewed an old magnetic resonance imaging (“MRI”) scan of Claimant's lumbar spine. (R. 294.) Dr. Koski found that Claimant suffered from “a very large disc herniation” with focal compression of her left S1 nerve root, consistent with her radiculopathy. (R. 294.)

         On February 8, 2012, Claimant underwent a left-sided minimally invasive L5-S1 laminotomy with microdiscectomy. (R. 273.) Dr. Koski, who performed the procedure at Northwestern Memorial Hospital, reported that the surgery was without complications. (R. 274.) Claimant was discharged that same day. (R. 273.)

         On May 3, 2012, Claimant returned to Dr. Koski for a scheduled follow-up appointment. (R. 280.) She reported that she had been doing very well with no residual leg pain until a few days earlier, when she lifted two gallons of water and felt something “shift” and “pop, ” causing a recurrence of left leg pain. (R. 280.) She stated that, although the pain was not nearly as severe as before, it was similar in distribution and it was worrisome to her. (R. 280.) Dr. Koski noted that Claimant had 5/5 strength in all major motor groups in the bilateral lower extremities. (R. 280.) Dr. Koski thought Claimant was fine to begin physical therapy and he prescribed a Medrol Dosepack. (R. 280.) The doctor felt that Claimant's symptoms pointed to potential recurrent disc herniation. (R. 280.) An MRI done on May 17, 2012, confirmed Dr. Koski's fears: it showed a “persistent left foraminal disc protrusion at ¶ 5-S1” and “suspected unilateral right L5 pars defect.” (R. 284.)

         Dr. Koski referred Claimant to Dr. Geeta Nagpal for pain management on July 25, 2012. (R. 297.) At this examination, Claimant described her pain as 4/10. (R. 298.) Dr. Nagpal suspected that Claimant may have re-injured herself following her microdiscectomy. (R. 297.) Dr. Nagpal's notes indicate that Claimant's goals were “to be more active” and return to work as a landscaper / heavy equipment operator. (R. 298.) During the examination, Dr. Nagpal administered a left L5-S1 epidural steroid injection. (R. 298.) Immediately following the injection, Claimant reported 50% pain relief. (R. 303.)

         Claimant continued her follow-up visits with Dr. Koski at the at Neurosurgery Clinic at Northwestern Memorial Hospital. In a letter dated August 16, 2012, Dr. Koski described Claimant's condition, stating she was still “attempting conservative measures to help with her pain.” (R. 232.) Dr. Koski opined that Claimant had been unable to work since her surgery. (R. 232.)

         Claimant was back to see Dr. Nagpal the next day. Claimant reported that after the first steroid injection, she had excellent relief for her pain, but this only lasted for a few days before the pain returned to the same level or worse. (R. 305.) Claimant was given another left L5-S1 epidural steroid injection, which immediately resulted in a 70% reduction of pain. (R. 306-307.) By September 4, 2012, however, Claimant's pain was back at its previous level and a third injection was ruled out. (R. 310-312.) Conservative treatment with Vicodin, Ibuprofen, and Flexeril had failed as well. (R. 312.) Dr. Nagpal noted that, if Claimant was not benefitting from the steroid injections, another surgery might be necessary. (R. 309.)

         On October 2, 2012, Claimant returned to Dr. Koski, reporting persistent pain with no lasting relief from the epidural steroid injections. (R. 282, 315.) In his notes, Dr. Koski stated that she “overall is fairly disabled by these symptoms” and he recommended a transforaminal lumbar interbody fusion. (R. 282, 315.) Claimant was also developing neck and shoulder pain. An MRI of her cervical spine, performed October 26, 2012, showed “multilevel degenerative changes … most severe at ¶ 5-C6 where there is a central disk protrusion causing mild ventral impression on the cord consistent with mild central canal stenosis.” (R. 336.) There was also “mild left neuroforaminal stenosis at this level.” (R. 336.)

         And, so, it was another surgery for Claimant. On November 8, 2012, she underwent an L5-S1 transforaminal lumbar interbody fusion with an iliac bone harvest. (R. 347-48, 364, 370.) On November 11, 2012, Claimant was discharged in stable condition. (R. 372, 374.) She was instructed not to engage in any strenuous activity: she wasn't to lift more than five or ten pounds, not drive until cleared by her doctor, bend or twist at the waist, or sit for more than twenty or thirty minutes without getting up. (R. 372-373, 405.)

         After her surgery, Claimant continued to go to Northwestern Memorial Hospital Clinic for regular follow-ups. On November 28, 2012, Claimant reported that her left leg pain had resolved, but that she had new right radicular pain, which was “mild and intermittent.” (R. 462.)

         On December 5, 2012, Dr. C. A. Gotway reviewed Claimant's medical file on behalf of the state disability agency, and he arrived at a residual functional capacity (“RFC”) finding. He felt that, from the date of her car accident until her lumbar fusion (R. 67), Claimant could occasionally lift and carry up to twenty pounds, and could frequently lift up to ten pounds; could stand and/or walk for six hours in an eight-hour day; could sit for six hours in an eight-hour day; and had no limitations in pushing or pulling. (R. 67-68.) Claimant could only occasionally bend at the waist or bend at the knee, but she was not limited in her ability to crawl, or climb ramps, stairs, ladders, ropes, or scaffolds. (R. 68.) Dr. Gotway also offered an RFC finding for the period “12 Months After Alleged Onset Dated: 08/26/2012.” (R. 69.) He noted that Claimant underwent lumbar fusion surgery on November 8, 2012, and explained that “[g]iven a normal recovery, the claimant should be able to perform light work activity by 11/08/13, 12 months after her surgery.” (R. 69.) Dr. Gotway based his assessment on the medical evidence and Claimant's statements of how her condition affected her ability to work. (R. 72.)

         On December 18, 2012, six weeks post-surgery, Claimant reported hypersensitivity in her right foot and right lateral calf. (R. 473.) She denied any new numbness, weakness, or bladder complaints, but she “was concerned about her pain control.” (R. 473.) She was experiencing headaches and vomiting from the Norco; as a result, she had been taking Tylenol instead, although it wasn't nearly as effective. (R. 473.) Claimant was prescribed Neurontin 300 mg at bedtime for seven days, and Tramadol was substituted for Norco, in the “the hope of less side effects.” (R. 473.) Claimant was also referred for physical therapy and massage therapy. (R. 472-474.)

         Three months post-surgery, on January 30, 2013, Claimant reported that her left posterior left leg pain had completely resolved. (R. 481.) She also reported that her right radicular pain had resolved as well. (R. 481.) Claimant denied any new numbness, weakness, or bladder complaints. (R. 481.) She still had some back pain with certain ...


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