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Gulik v. Berryhill

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

August 2, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.



         On October 17, 2012, Mary Anne Gulik filed for disability benefits, claiming an onset date of December 18, 2011 (R. 151), later amended to December 15, 2010 (R. 160).[3] After her application was denied initially and on reconsideration, Ms, Gulik received a hearing before an Administrative Law Judge ("ALJ"). On December 17, 2014, the ALJ issued a written decision denying her request for benefits. The Appeals Counsel denied Ms. Gulik's request for review, making the ALJ's opinion the final decision of the Commissioner (R. 1). Presently before this Court is Ms. Gulik's motion to reverse and remand the ALJ's decision (doc. # 14). The motion is now fully briefed. For the reasons that follow, we grant Ms. Gulik's motion to remand.


         Ms. Gulik has complained to physicians of pain in her upper (cervical) back or neck, lower (lumbar) back radiating down her right leg and right knee since late 2010, when she was 38 years old (R. 260-65). MRIs at that time showed only minimal degenerative changes (Id.), but her pain continued. On February 4, 2011, Ms. Gulik had one visit with a rheumatologist, Richard M. Keating, M.D. (R. 431). Dr. Keating's report stated that the physical examination showed "numerous myofascial tender points with minimal palpation, " and he opined that Ms. Gulik had fibromyalgia syndrome (R. 430-31).[4]

         On February 28, 2011, Ms. Gulik began treatment for her pain with Faris Abusharif, M.D., of Pain Treatment Centers of Illinois; she described her lower back pain as radiating down her right lower extremity, particularly in her hip (R. 270-71). In March and April 2011, Dr. Abusharif administered lumbar, cervical and hip epidural injections to treat Ms. Gulik's pain, and prescribed her medications including Lyrica (nerve pain medication), Flexeril (muscle relaxant), and Norco (narcotic) (R. 272, 275). This treatment provided little lasting relief, and in June 2011, Dr. Abusharif administered another lumbar injection and increased Ms. Gulik's prescription for Norco, discontinued the prescription for Lyrica, and added a prescription for Neurontin (nerve pain medication and anti-convulsant) (R. 277-79). In July and August 2011, Dr. Abusharif administered another cervical injection and an injection into Ms. Gulik's right knee (R. 281, 285). In October 2011, Neurontin was discontinued due to side effects, and Ms. Gulik was prescribed amitriptyline (an anti-depressant used to treat fibromyalgia pain) (R. 287).

         During a visit to Dr. Abusharif in December 2011, Ms. Gulik reported that her lower back and right lower extremity pain had escalated to a constant, stabbing level of 9 out of 10 and was exacerbated by sitting, standing or walking (R. 288). Dr. Abusharif administered a right sacroiliac joint steroid injection and added a prescription for Savella (nerve pain medication and antidepressant) (R. 289). His report of that visit also stated that Ms. Gulik consulted with a surgeon, Dr. Tony Rinella, who felt surgery was not a "necessary option" and recommended that Ms. Gulik continue with non-surgical treatment for her pain (R. 288). That month, Ms. Gulik stopped working as a certified nursing assistant because the pain in her legs made her unable to lift patients (R. 195).

         Telephone records from the Pain Treatment Centers indicate that Ms. Gulik's pain did not abate in the first half of 2012. A record of a February 2012 call indicated that Ms. Gulik's pain was so severe - despite taking Norco - that she did not want to wait four days for her steroid injection (R. 496). And, in April 2012, Ms. Gulik asked for and received a refill of Flexeril (Id.).

         In July and August 2012, Ms. Gulik had additional imaging of her lumbar spine, which showed early degenerative disc disease, annular tears and some disc protrusion (R. 297-98, 300). On August 21, 2012, Dr. Abusharif performed a lumbar discogram - an invasive test to evaluate the cause of back pain - because despite repeated epidural injections, Ms. Gulik's pain recurred (R. 301).[5] Dr. Abusharif determined that at ¶ 4-L5, there was a broad-based posterior disc protrusion abutting L5 nerve roots and bilateral foraminal extensions of the disc abutting L4 nerve roots, as well as a grade IV radial tear in the posterior aspect of the disc (R. 305). The next month, September 2012, Ms. Gulik reported continuing sharp pain in her low back radiating down her right lower extremity, and her pain medication was listed as Savella, Percocet (narcotic) and Lyrica (R. 306), with a refill of Flexeril approved in December 2012 (R. 495).

         On January 3, 2013, Ms. Gulik reported a partial decrease of pain symptoms in the cervical region after an injection, but she had severe low back pain radiating down the right leg causing periods of weakness, tingling and numbness in her lower extremities (R. 381). Dr. Abusharif prescribed Medrol (anti-inflammatory), and changed Ms. Gulik's narcotic prescription from Percocet to OxyContin (R. 381-83). On January 9, 2013, Ms. Gulik consulted with Daniel Troy, M.D., at the Midwest Bone Joint Spine Institute on a referral from Dr. Abusharif to see if there was "anything further that [he] could possibly do to entertain and relieve her symptoms, " which had not resolved with injections (R. 294). Dr. Troy recommended that Ms. Gulik continue with non-surgical treatment options at that time (R. 294-95).

         In January 2013, Ms. Gulik also reported increasing pain over her right saroiliac ("SI") joint (joint between lower spine and pelvis), lateral hip and anterior thigh (R. 332). On January 15, 2013, Benjamin Domb, M.D., of Hinsdale Orthopaedics, ordered an MRI, which showed a tear in the right hip labral (cartilage) (R. 330). On January 24, 2013, Ms. Gulik complained to Dr. Domb of worsening SI joint pain and right hip pain and associated radiculopathy from her lumbar spine; examination showed decreased range of motion, pain, and tenderness (R. 328-29). Dr. Domb gave her a lidocaine injection in the hip and recommended physical therapy for "a last trial of non-operative treatment" (R. 330-31). The next day, Dr. Abusharif administered a right sacroiliac joint injection for her low back, right buttock and right leg pain (R. 386). On February 22, 2013, Ms. Gulik reported that although she had some pain relief since her injection, she still had severe pain in her low back radiating down her right lower (R. 387).

         On March 13, 2013, a non-examining state agency physician opined based on the medical record that Ms. Gulik could perform sedentary work - lift up to ten pounds occasionally, stand or walk for a total of two hours, and sit for a total of about six hours in an eight-hour workday (R. 80-82). This opinion was affirmed on reconsideration on September 27, 2013, after consideration of additional evidence submitted by Ms. Gulik (R. 85-91).

         On April 8, 2013, Dr. Abusharif administered another lumbar epidural steroid injection, and Ms. Gulik continued to take OxyContin, Flexeril, Savella and Lyrica for her pain (R. 391). The next day, Ms. Gulik returned to Dr. Domb, reporting no relief in her hip, low back and SI joint pain (R, 366-68). Dr. Domb determined that because Ms. Gulik "failed to improve with conservative measures of physical therapy, activity modification and treatment of her SI joint and back, " she was a candidate for right hip arthroscopy to repair her labral tear (R. 368). Dr. Domb performed the right hip arthroscopy on April 17, 2013 (R. 326-27). After the surgery, Ms. Gulik had physical therapy through July 2013 to help decrease pain and improve her range of motion (R. 335, 357). She also exercised, including riding her bike two hours per day (R. 335). On July 25, 2013, Dr. Domb reported that Ms. Gulik's hip was 80 percent improved from the surgery but that she still experienced weakness and occasional soreness with prolonged standing and decreased range of motion in her hip (R. 362).

         Ms. Gulik continued to visit the Pain Treatment Center. On July 18, 2013, Dr. Abusharif administered a right SI joint injection and bilateral neck trigger point injections, and Ms. Gulik continued to take Flexeril, Lyrica, OxyContin and Savella (R. 392). On August 15, 2013, Ms. Gulik reported 80 percent pain reduction since the injection, but described continued pain her lower back with radiation into the right buttock and hip (R. 393). On October 3, 2013, Dr. Abusharif administered a cervical epidural steroid injection for Ms. Gulik's neck pain, which radiated down her arms (R. 490), but on November 4, 2013, Ms. Gulik reported that she had no reduction in pain after that injection (R. 488). Later that month, Dr. Abusharif administered a lumbar epidural steroid injection (R. 504), However, Ms. Gulik reported that her pain relief from that injection lasted only one week, and in December 2013 and January 2014, she continued to have severe pain in her lower back and hips, radiating down her legs (R. 481, 484).

         On November 14, 2013, James T. Niemeyer, D.O., reported that Ms. Gulik had an adverse reaction to the October 2013 cervical injection; after the injection, she had trouble breathing (R. 451).[6] Ms. Gulik also reported that her neck pain and headaches were getting worse, as was her thoracic (mid-back) pain (Id.), Dr. Niemeyer reported that examination revealed "chronic tissue texture changes in the cervical paraspinal, " and he performed osteopathic ...

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