United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
Kathleen B. Burke, United States Magistrate Judge
Kevin Secka (“Plaintiff” or “Secka”)
seeks judicial review of the final decision of Defendant
Commissioner of Social Security (“Defendant” or
“Commissioner”) denying his application for
social security disability benefits. Doc. 1. This Court has
jurisdiction pursuant to 42 U.S.C. § 405(g). This case
is before the undersigned Magistrate Judge pursuant to the
consent of the parties. Doc. 14. As explained more fully
below, the Court is unable to assess whether the decision of
the Administrative Law Judge (“ALJ”) is supported
by substantial evidence because the ALJ's finding that
Secka did “not have any neurological deficits”
appears, in the absence of further explanation, to be
contrary to the evidence of record. Accordingly, the Court
REVERSES and REMANDS the Commissioner's decision for
proceedings consistent with this Opinion.
protectively filed an application for Disability Insurance
Benefits (“DIB”) on August 23,
2012. Tr. 41, 119, 147, 255-256, 324. Secka
alleged a disability onset date of June 1, 2010. Tr. 41, 119,
255, 324. Secka alleged disability due to disc degeneration,
arthritis, nerve damage, depression, back injury, and high
blood pressure. Tr. 119, 167, 177, 328. Secka's
application was denied initially (Tr. 167-175) and upon
reconsideration by the state agency (Tr. 177-183).
Thereafter, he requested an administrative hearing. Tr.
24, 2014, an administrative hearing was conducted by
Administrative Law Judge John C. Lyons (“ALJ”).
Tr. 61-89. On January 14, 2015, the ALJ issued his decision.
Tr. 38-60. In his decision, the ALJ determined that Secka had
not been under a disability within the meaning of the Social
Security Act from June 1, 2010, through the date of the
decision. Tr. 42, 53. Secka requested review of the ALJ's
decision by the Appeals Council. Tr. 37. On May 2, 2016, the
Appeals Council denied Secka's request for review, making
the ALJ's decision the final decision of the
Commissioner. Tr. 1-6.
Personal, vocational and educational evidence
was born in 1973. Tr. 255. He was 41 years old at the time of
the hearing and lived in a house with his fiancé, his
fiancé's adopted 2-year old son and 19 year-old
daughter. Tr. 63-64. Also, Secka's fiancé's
22-year old son lived with them while he was not attending
college. Tr. 63. Secka's minor daughter used to live with
him but lived with her mother since 2013. Tr. 50, 63, 64.
Secka graduated from high school and attended New Castle
School of Trade in New Castle, PA, where he earned an
Associate's Degree in Applied Sciences in Heating and
Cooling in 2001. Tr. 329, 613. Secka last worked in 2010. Tr.
has a history of back pain dating back to at least 2005 when
he underwent a bilateral L5-S1 lumbar microdiscectomy on
November 22, 2005. Tr. 401-402, 409-410, 415-416, 425. Dr.
Parviz Baghai, M.D., a neurosurgeon associated with Allegheny
General Hospital performed the surgery. Tr. 409-410, 425.
Following his surgery, Secka returned to work. Tr. 423.
October 23, 2006, Secka returned to see Dr. Baghai reporting
he had been doing well up until three weeks prior. Tr. 423.
Secka had experienced low back pain when he moved suddenly
while in bed. Tr. 423. Following that, he was carrying a
furnace and experienced an increase in his symptoms. Tr. 423.
He was able to continue work until a week prior to his visit
with Dr. Baghai when he fell at work. Tr. 423. Dr.
Baghai's examination showed a positive straight leg raise
at about 60 degrees bilaterally and some give-way weakness in
both dorsiflexors. Tr. 423. Dr. Baghai diagnosed recurrent
lumbar radiculopathy and ordered an EMG and MRI of the lumbar
spine. Tr. 423. On November 13, 2006, Secka saw
his treating physician Michael T. Guffey, M.D., regarding his
back pain. Tr. 458.
continued to see Dr. Guffey in 2006 and in 2007 with reports
of back pain with the pain radiating down into his legs. Tr.
453-460. In March 2007, a lumbar spine MRI was performed. Tr.
472-473. Dr. Guffey indicated that the MRI showed a moderate
bilateral foraminal stenosis and a mild spinal stenosis at
the L5-S1 level, which is where Secka had his prior
microdiscectomy. Tr. 454. Dr. Guffey noted that Secka might
require further surgery and he referred Secka to Dr. Baghai
for surgical evaluation. Tr. 454. Also, in early 2007, Secka
saw Dr. Michael R. Cozza, M.D., for pain management at Beaver
Valley Rehabilitation Associates. Tr. 439-442. Physical
therapy was attempted without improvement. Tr. 441.
2007, Secka filed applications for social security
disability. Tr. 44, 90-92. However, Secka received some
relief from injections and, on June 12, 2008, he notified
social security that his condition had improved and he no
longer wanted to pursue his social security disability
application. Tr. 44, 71, 159.
1, 2010, Secka experienced an injury at work while lifting a
bread machine. Tr. 574, 566. He experienced pain in his low
back and up and down both legs. Tr. 574. Following his work
injury, on August 3, 2010, Secka started pain management
treatment. Tr. 489-492. He saw Dr. LoDico at Advanced Pain
Medicine. Tr. 489-492. Secka reported pain across his entire
low back with radiation into the lateral and posterior
aspects of bilateral lower extremities. Tr. 489. He reported
numbness, tingling, and burning sensation in the same areas.
Tr. 489. Secka also reported weakness in his bilateral lower
extremities but denied falling as a result of the weakness.
Tr. 489. Secka reported little relief obtained through the
use of pain medication, TENS unit, or physical therapy. Tr.
489. On physical examination, Dr. LoDico observed that Secka
was able to sit and converse comfortably with no
demonstration of overt pain behaviors; he rose from a seated
position with the assistance of arms; his gait was
nonantalgic; he walked with his lumbar spine slightly flexed
forward due to pain; he was able to heel walk, toe walk, and
squat with moderate difficulty secondary to pain; he had
moderate tenderness to palpation in the midline and bilateral
lumbar paraspinal muscles; lower extremity strength
evaluation showed 5 out of 5 muscle strength in bilateral hip
flexion, knee flexion/extension, ankle dorsiflexion/plantar
flexion; he had decreased sensation to light touch in the
lateral aspects of the right lower leg distal to the knee; he
had decreased sensation to temperature in the lateral aspects
of bilateral lower legs; straight leg raise was positive on
the right and negative on the left; and there were no
palpable cords, muscle spasms or true trigger points. Tr.
490. Dr. LoDico's assessment was “Lumbar spinal
pain secondary to discogenic syndrome versus facet
arthropathy, history of lumbar spine diskectomy in 2005[.]
Lumbar extremity radicular syndrome. Significant pain relief
after lumbar epidural steroid injections in the past.”
Tr. 490-491. Dr. LoDico recommended lumbar epidural steroid
injections as well as a lumbar MRI and possible EMG nerve
conduction studies of the bilateral lower extremities. Tr.
had injections administered on August 6 and August 20, 2010.
Tr. 493-495, 496-498. On September 15, 2010, Secka reported
that, since the two injections, he was nearly 100% improved.
Tr. 499. Secka declined further injections at that time and
Secka was advised to call to schedule another injection if
his symptoms increased. Tr. 499. About two weeks later, on
September 28, 2010, Secka reported that his lumbar spinal
pain had increased significantly. Tr. 501. Secka was started
on Hydrocodone, EMG nerve conduction studies of the bilateral
lower extremities were scheduled, and a referral to a
neurosurgeon was made for evaluation of possible surgical
intervention. Tr. 501.
nerve conduction studies were performed on October 1, 2010,
which showed bilateral L4 and right L5 radiculopathy without
new or active denervation, bilateral tibial motor
mononeuropathy, bilateral sural sensory mononeuropathy. Tr. 504,
510, 560-562. On October 7, 2010, Secka continued to report
increased pain and indicated that the Hydrocodone was not
helping. Tr. 504. Secka's October 7, 2010, physical
examination was generally normal aside from his gait being
slow, squatting with some discomfort, and rising from a
seated position with the assistance of his arms. Tr. 504.
Hydrocodone was discontinued and Secka was prescribed Opana,
Lyrica, and Mobic. Tr. 505. On October 20, 2010, Secka
reported increased pain in his back, with improvement noted
with flexing forward. Tr. 507. Secka reported no side effects
from the Opana but stated that it was not helping adequately
with his pain. Tr. 507. He requested an increase in the
dosage. Tr. 507. Physical examination revealed that Secka was
uncomfortable but in no acute distress; he rose from a seated
position slowly with the assistance of his arms and walked in
a forward flexed position; his gait was slow and antalgic; he
was tender over the bilateral lumbar paraspinal muscles, the
right more than the left and over the lumbar area midline;
there were no palpable cords or muscle spasms seen; muscle
strength testing revealed 4 out of 5 strength in the
bilateral quadriceps secondary to pain and 5 out of 5
strength in the balance of his bilateral lower extremities;
straight leg raises were negative bilaterally. Tr. 507.
Secka's Opana was increased from 5 mg to 7.5 mg. Tr. 507.
A new Lyrica prescription was provided because Secka
indicated he could not fill the prior prescription because
there was no diagnosis included with the initial
prescription. Tr. 507. Also, Secka was prescribed a Medrol
dose pack to be taken for exacerbation of pain. Tr. 507.
saw Dr. Baghai on October 29, 2010. Tr. 566, 571-576. Dr.
Baghai observed that Secka had tried physical therapy without
relief; injections helped for about a week; Lyrica was
helping but Secka's back pain was still significant; and
the steroid dose pack was not helping. Tr. 566. Dr.
Baghai's physical examination showed positive straight
leg raise at about 60 degrees bilaterally with pain in the
back and legs. Tr. 566. A neurological examination showed no
focal deficits. Tr. 566. Dr. Baghai reviewed a lumbar MRI,
noting that it showed evidence of postoperative changes at
¶ 5-S1. Tr. 566. Dr. Baghai recommended that Secka
continue with conservative treatment, indicating that he
believed that the majority of Secka's symptoms were the
“result of stressor during the incident of June 1,
2010.” Tr. 566.
continued treatment at Advanced Pain Medicine in November and
December 2010 with continued reports of pain. Tr. 510-515.
Secka indicated that Opana at 10 mg was not helping. Tr. 514.
His dosage was increased to 15 mg on December 8, 2010. Tr.
514. Lumbar facet nerve blocks, lumbar facet rhizotomy and a
lumbar diskopgraphy were discussed as possible future
procedures. Tr. 511, 514.
January 7, 2011, Secka had bilateral lumbar facet nerve
blocks. Tr. 516-518. On January 11, 2011, Secka had a left
lumbar facet rhizotomy. Tr. 519-522. Secka reported some
improvement from the procedures. Tr. 519 (80% relief for rest
of the day from nerve block); Tr. 523 (less left lower
extremity pain following the lumbar rhizotomy but increased
cramping pain and pressure on the left side and back).
his January 17, 2011, visit at Advanced Pain Medicine, Secka
reported that Opana was not helping so he stopped taking
after two weeks. Tr. 523. Also, while Lyrica was helping his
lower extremity pain, he discontinued because it was causing
forgetfulness. Tr. 523. On examination, Secka's gait was
antalgic, favoring the left lower extremity; and he was
tender to palpation of the lumbar paraspinal muscles
bilaterally. Tr. 523. Dr. LoDico recommended a right lumbar
facet rhizotomy and that Secka restart Lyrica. Tr. 523. A
week later, Secka reported that his pain had worsened. Tr.
526. Dr. LoDico started Secka on MS Contin, continued Secka
on Lyrica, suggested Tylenol, and indicated that, once
Secka's pain settled, a right lumbar facet rhizotomy
should be considered. Tr. 526. At a February 10, 2011,
follow-up visit, Secka reported that the MS Contin was not
working and caused vomiting. Tr. 529. He was not taking
Tylenol as suggested. Tr. 529. He was using Aleve. Tr. 529.
On physical examination, Secka appeared uncomfortable at
times; he rose from a seated position slowly with assistance
of his arms; and his gait was slow but not antalgic. Tr. 529.
Otherwise, his physical examination was unremarkable. Tr.
February 28, 2011, Secka had a right lumbar facet rhizotomy.
Tr. 536. Following the procedure, on March 10, 2011, Secka
reported a significant decrease in his lower extremity pain
but was not sure whether it was attributed to the rhizotomy
procedure or changes in his medication. Tr. 536. He was still
having pain across his back and dorsal aspect of his feet as
well as intermittent mild pain in the lateral thigh. Tr. 536.
Physical examination findings were generally normal. Tr. 536.
continued pain management treatment at Advanced Pain Medicine
through September 2011, receiving lumbar epidural injections
on June 21, August 2, and August 22, 2011. Tr. 539-559.
During a September 6, 2011, visit at Advanced Pain Medicine,
it was noted that Secka received some relief from the series
of injections. Tr. 557. The first injection helped for about
a week but the back pain returned after Secka's left leg
fell through the floor at his cabin. Tr. 548, 557. The second
and third injections helped with lower extremity pain but his
pain was not completely relieved. Tr. 557. Secka reported
that a worker's compensation doctor opined that Secka
could return to full duty work. Tr. 557. Secka reported a new
pain in his groin and going into his bilateral lower
extremities that he described as quick and intermittent -
sharp and burning like being electrocuted. Tr. 557.
Secka's physical examination was generally normal. Tr.
557. Dr. Plowey of Advanced Pain Medicine recommended a
lumbar diskography. Tr. 557. Dr. Plowey noted that Secka last
worked in a job requiring significant lifting, bending,
twisting and prolonged standing and it was unlikely that
Secka could return to that type of work at the time, stating
that “we will have him remain off of full duty at this
time. He is restricted to sit, stand and walk ad lib. with no
lifting greater than 10 pounds.” Tr. 557.
October 10, 2011, Secka returned to see Dr. Baghai. Tr. 565.
Secka reported that his symptoms had been increasing over the
prior year and Dr. Baghai indicated that an examination
showed “straight leg raising is positive on the left at
about 60 degrees. The remainder of his exam does not show any
focal neurological deficit.” Tr. 565. Dr. Baghai
recommended a lumbar MRI and EMG and nerve conduction testing
of both legs. Tr. 565.
lumbar MRI was taken on October 12, 2011. Tr. 567. No
significant changes were seen from the prior June 2010 MRI.
Tr. 567. There continued to be a mild diffuse bulge at ¶
5-S1 but no significant central canal narrowing was seen;
mild bilateral neural foraminal and narrowing and lateral
recess narrowing was unchanged. Tr. 567. EMG nerve conduction
studies of the lower extremities were performed on October
17, 2011. Tr. 568-570. Physical examination of the lower
extremities showed hypoactive deep tendon reflexes; sensation
appeared preserved to pinprick, light touch and vibration
sense with some patchy alteration noted on both feet; pedal
pulses were palpable; and no footdrop phenomenon was noted.
Tr. 600. The nerve conduction studies were abnormal, with the
following findings noted:
Axonal impairment noted in the right tibial nerve, on the EMG
studies diffuse chronic partial denervation changes were seen
in multiple myotomes. The abnormalities noted are most
consistent with a chronic lumbosacral polyradiculopathy, no
abnormalities suggestive of a recurrent acute lumbosacral
radiculopathy was noted.
Tr. 568, 600.
Baghai saw Secka on October 24, 2011. Tr. 564. Secka reported
continued left leg numbness that was sharp, aching, stabbing,
burning and tingling. Tr. 564. Dr. Baghai reviewed the MRI
and EMG and nerve conduction study results and recommended a
spinal cord stimulator and further evaluation. Tr. 564.
left Advanced Pain Medicine due to a change in his insurance
(Tr. 643), and, beginning in April 2012, he started pain
management treatment at Allied Pain Treatment Center and
continued with treatment there through 2013 (Tr. 587-595,
603-611, 623-642). In January 2014, Secka resumed treatment
at Advanced Pain Medicine and continued treatment there
through at least April 2014. Tr. 643-664.
his April 17, 2012, office visit at Allied Pain Treatment
Centers with Dr. Thomas Ranieri, M.D., physical examination
findings included decreased range of motion; pain on flexion,
extension, rotation, side bend; positive straight leg
testing; positive Patrick's testing for back; positive
heel walk and toe walk; no motor or sensory deficits. Tr.
587. Dr. Ranieri assessed post op lumbar laminectomy, lumbar
spondylosis, lumbar facet syndrome, and noted a re-injury in
June 2011 that was not worker's compensation. Tr. 587.
returned to see Dr. Ranieri a month later on May 15, 2012,
with continued reports of low back pain into his legs. Tr.
588. Dr. Ranieri's physical examination findings included
decreased range of motion in the lumbar spine; pain on
flexion, extension, rotation and side bend; decreased
strength; positive straight leg testing bilaterally, left
greater than the right; positive Patrick's testing for
back pain; inability to heel walk and toe walk; antalgic
gait; decreased sensation in L5-S1 distribution in legs and
median nerve distribution in hands; no motor or sensory
deficits. Tr. 588. Dr. Ranieri assessed neuropathic pain of
the lumbar spine area; lumbar spine neuritis; post op lumbar
laminectomy 2005; median neuropathy; lumbar spondylosis;
lumbar facet syndrome; and noted a re-injury in June 2011
that was not worker's compensation. Tr. 588.
13, 2012, spinal mapping of Secka's left side of the
lumbar spine was negative for pain at the L3 area but
positive at the L4 and L5 areas. Tr. 590. In July 2012, Secka
saw Dr. Secka and reported having fallen in a rabbit hole a
couple weeks earlier. Tr. 603. On physical examination, Secka
continued to exhibit decreased lumbar spine range of motion,
positive Patrick's testing and positive straight leg
testing. Tr. 603. On August 21, 2012, Secka saw Dr. Ranieri
reporting that he had fallen into a hole that his dog dug
and both of his legs were hurting him. Tr. 605. Dr.
Ranieri's physical examination findings included
decreased range of motion, positive straight leg testing,
positive Patrick's testing for back pain, and positive
heel walk and toe walk. Tr. 605. Dr. Ranieri noted that Secka
had had good results from lumbar epidural steroid injections
in the past and indicated that injections would be set during
a subsequent visit. Tr. 606. On October 17 and November 14,
2012, Secka received lumbar epidural steroid injections. Tr.
610, 623-624, 625-626. On December 14, 2012, Secka saw Dr.
Ranieri reporting that the injections did not help. Tr. 627.
January 2013, Secka reported falling when his dog got under
his feet. Tr. 629. Dr. Ranieri's physical examination
findings included decreased range of motion, positive
straight leg testing, positive Patrick's testing for back
pain, and positive heel walk and toe walk. Tr. 605. On March
5, 2013, Secka saw Dr. Ranieri for his low back pain. Tr.
631-634. Physical examination findings were generally normal
with tenderness in the ...