United States District Court, N.D. Illinois, Western Division
MEMORANDUM OPINION AND ORDER
D. Johnston United States Magistrate Judge
Neil Lutz brings this action under 42 U.S.C. § 405(g),
seeking a remand of the decision denying him social security
disability benefits. For the reasons set forth below, the
decision is remanded.
20, 2011, Plaintiff filed applications for disability
insurance benefits and supplemental security income.
Plaintiff alleged a disability beginning on September 1,
2008, because of chronic neck and back problems and
depression and anxiety. R. 220, 228, 270.
2007, Plaintiff reported to his primary care physician that
he was having headaches on a daily basis, noting that he was
in a car accident when he was 16 years old and injured his
neck. R. 363. An MRI revealed disk bulging and herniation. R.
363. Plaintiff was prescribed Flexeril for muscle spasms and
Vicodin for his pain. R. 364.
September 2008, Plaintiff began treating with a spinal
surgeon, Dr. Christopher Silva, due to complaints of back and
left leg pain. R. 413. He was diagnosed with a disk
herniation at ¶ 5-S1 with radiculopathy. R. 414. On
September 17, 2008, he received an epidural injection, but it
did not relieve his back pain. R. 423. Subsequently, he
underwent a total of three back surgeries and a neck surgery
to relieve his pain.
first surgery, a L5-S1 laminotomy with partial discectomy,
occurred on September 29, 2008. R. 431. Following surgery,
Plaintiff reported that his leg pain was gone, and he
returned to his job as a welder. R. 390, 412. Plaintiff
continued to work through the end of December 2008, when he
reinjured his back wrestling with his son. R. 384. Plaintiff
went to the emergency room and was given Flexeril and Vicodin
for his pain. R. 384. An MRI from January 2009 revealed small
recurrent disk herniation at ¶ 5-S1. R. 405. Plaintiff
was given a Medrol dosepak and was told to get an epidural
injection. R. 405. His doctor recommended surgery if
Plaintiff did not improve with this treatment. R. 405.
January 2010, Plaintiff was still taking Flexeril and Vicodin
for his pain. R. 351. He also started seeing a new doctor,
Dr. Kevin Draxinger, after he fell and experienced pain
radiating down his left leg that left him barely able to
walk. R. 351. Due to continued disc herniation at ¶ 5-S1
and some foraminal narrowing at ¶ 4-5, Plaintiff
underwent a second back surgery on January 18, 2010. R. 352,
429. Dr. Draxinger performed an L5-S1 revision discectomy. R.
weeks following his surgery, Plaintiff still complained of
pain and began taking Percocet. R. 353. By February 2010,
Plaintiff reported feeling somewhat better, taking only 3
Percocet a day. R. 354. In March 2010, Plaintiff still had
periodic “stinging in his leg, ” and began using
Vicodin instead of Percocet. R. 355, 365. Plaintiff also
reported ongoing problems with his neck, which caused
“headaches fairly often.” R. 355. A cervical MRI
revealed a “2- level disk bulging and herniation,
” which was consistent with the cervical MRI taken in
2007. R. 356. Plaintiff's doctor discussed the possible
need for cervical disk replacement surgery. R. 356.
April 2010, Plaintiff returned to see Dr. Silva, complaining
of leg and back pain and weakness despite his most recent
surgery. R. 396-98. Dr. Silva diagnosed Plaintiff with
recurrent disk herniation at ¶ 5-S1 with severe
radiculopathy and disk herniation at ¶ 4-5 with
radiculopathy. R. 393, 425. As a result, Plaintiff had back
surgery a third time on May 20, 2010. R. 424. Dr. Silva
performed a lumbar fusion at ¶ 4 to the sacrum and L4-S1
laminectomy. R. 424. Following surgery, Plaintiff still had
pain in his back and left leg, and he was prescribed Norco
and Flexeril. R. 381-82. In June and July 2010, Plaintiff
still had back and leg pain and complained of side-effects
from his continued use of narcotic pain medication. R. 366,
389. Plaintiff's MRI from July 2010 showed no disk
herniation. R. 422.
August 18, 2010, Plaintiff followed up with Dr. Silva,
complaining of left leg pain, despite the use of pain
medication. R. 388. Dr. Silva's examination revealed that
Plaintiff had some tenderness in his back and diminished
sensation in his calf, but had normal motor strength and
“no residual stenosis.” R. 388. In September
2010, Plaintiff was limiting his use of Vicodin by using
Gabapentin, but complained that it did not help with his
chronic back pain. R. 367. In October 2010, Plaintiff
reported treating at Rosecrance to eliminate his dependence
on narcotic pain medication and his desire to stay off
narcotics. R. 368. Nevertheless, by September 2011, Plaintiff
again was dependent on Norco for pain control. R. 507.
2011, Dr. Silva evaluated Plaintiff's neck pain. R. 387.
An MRI revealed “[c]ervical degenerative disk disease
at ¶ 3-4 and C4-5 with minimal and episodic
radiculopathy.” R. 387. Dr. Silva prescribed physical
therapy, noting that if this did not work, Plaintiff would be
a candidate for cervical epidural injections. R. 387. In
September 2011, Dr. Silva noted that Plaintiff may need
treatment for his neck beyond injections, but that
Plaintiff's lumbar spine should be dealt with first. R.
542. Dr. Silver opined that there was nothing else that could
be done for Plaintiff's back, but ordered a CT scan of
his lumbar spine to evaluate healing of the prior surgery. R.
542. The CT scan revealed pseudoarthrosis at ¶ 5-S1.
R. 539-40. In November 2011, Dr. Silva opined that this may
require surgical reconstruction. R. 540. Plaintiff also
underwent an EMG, which was normal, except for “some
evidence of polyneuropathy.” R. 539, 543.
October 3, 2011, Plaintiff received a cervical injection for
his neck pain. R. 588. Plaintiff did not get relief from the
first injection, so he received a second one on October 24,
2011. R. 587. In November 2011, Dr. Silva informed Plaintiff
that his neck would require a fusion from C3-5, but Plaintiff
would have to stop smoking first. R. 539-40. By the end of
November 2011, Plaintiff quit smoking and was ready to
proceed with surgery on his neck, but ultimately cancelled
surgery in January 2012 because he was “unemployed and
unable to work.” R. 566-67.
February 2012, Plaintiff went to the emergency room
complaining of headaches. R. 654. Plaintiff was given Norco
at the hospital to relieve his pain. R. 667. In April 2012,
Plaintiff again quit smoking and his surgery was rescheduled
for June 2012. R. 565-66. However, due to
“transportation difficulties” Plaintiff again
canceled the surgery. R. 564. In August 2012, Plaintiff
returned to the emergency room complaining of headaches. R.
697. He received a prescription for Ibuprofen and Norco. R.
697. In September 2013, ...