United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
Kathleen B. Burke, United States Magistrate Judge.
Nathaniel Craig (“Craig”) seeks judicial review
of the final decision of Defendant Commissioner of Social
Security (“Commissioner”) denying his application
for Disability Insurance Benefits (“DIB”). 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. 11.
reasons stated below, the decision of the Commissioner is
protectively filed an application for DIB on July 3, 2013,
alleging a disability onset date of October 2, 2009. Tr. 20,
192. He alleged disability based on the following:
degenerative disc disease, high blood pressure, complicated
migraines with stroke-like symptoms, blood clots in legs and
lungs, asthma, diabetes, difficulties from back surgery,
pinched nerves in back and arthritis in back. Tr. 196. After
denials by the state agency initially (Tr. 107) and on
reconsideration (Tr. 119), Craig requested an administrative
hearing. Tr. 134. Prior to the hearing, Craig amended his
alleged onset date to February 4, 2012. Tr. 191, 39. A
hearing was held before Administrative Law Judge
(“ALJ”) Jeannine Lesperance on August 25, 2015.
Tr. 38-67. In her November 24, 2015, decision (Tr. 20-32),
the ALJ determined that there are jobs that exist in
significant numbers in the national economy that Craig can
perform, i.e. he is not disabled. Tr. 31. Craig requested
review of the ALJ's decision by the Appeals Council (Tr.
15) and, on August 25, 2016, the Appeals Council denied
review, making the ALJ's decision the final decision of
the Commissioner. Tr. 1-4.
Personal and Vocational Evidence
was born in 1967 and was 46 years old on the date his current
application was filed. Tr. 20, 42. A prior disability
application was denied on February 3, 2012. Tr. 22, 74-84.
Craig last worked as a semi-truck driver and dock worker in
2009. Tr. 45-46, 60-61.
Relevant Medical Evidence
taken of Craig's lumbar spine on March 23, 2010, showed a
small focal disc herniation at ¶ 4-5 posterolaterally on
the right, with some focal neural foraminal encroachment. Tr.
310. The L4-5 disc also had slightly decreased signal
intensity, suggesting some degenerative disc dehydration, and
showed minimal bulging that minimally indented the dural sac
anteriorly. Tr. 310.
fall of 2010, John Collis, M.D., performed a lumbar
laminectomy with foraminotomy on Craig. Tr. 253. On December
16, 2010, Craig returned to Dr. Collis and reported that his
pain was unchanged. Tr. 253. Dr. Collis remarked that Craig
had developed meralgia paraesthetica in his thighs:
“This has nothing to do with his surgery, but possibly
positioning.” Tr. 253. Dr. Collis believed that Craig
had decompression “around the before type-painful
area” and recommended epidural injections. Tr. 253.
September 21, 2011, Career Assessment Systems, Inc., compiled
a “comprehensive vocational evaluation report”
for Craig upon a referral from the Bureau of Vocational
Rehabilitation. Tr. 254-275. During the evaluation, Craig
reported chronic migraines that occurred approximately 3-4
times a week and lasted between 8 hours and two weeks and
varied in severity. Tr. 255. During a migraine he was unable
to function and spent the duration lying in a dark room with
an ice pack. Tr. 255. He also experienced the following
post-migraine effects: slurred speech, numbness in his face
and fingers, blurred vision, disorientation, and loss of
concentration. Tr. 255. He detailed his back history: a car
accident in 2003, his back surgery in 2010 which provided
minimal relief, and continuing back and neck pain and
stiffness and numbness in his legs and 3-4 fingers on both
hands. Tr. 255. The report concluded that Craig had a
“severe deficit in his ability to work in environments
requiring lifting, carrying, and standing due to diagnosed
back and nerve damage, and standing, sitting, and walking
restrictions.” Tr. 260. Craig had a “moderate
deficit in his ability to meet schedules and maintain good
attendance, due to the diagnosed migraine headaches and
related effects” and “a severe deficit in his
ability to meet the demands of high performance work
environments.” Tr. 260. He was assessed as functioning,
overall, on an average level, “suggesting a relative
ability to function independently in most competitive
employment environments at this time.” Tr. 259. The
report concluded that Craig “is a
viable candidate for competitive employment at this
time.” Tr. 267 (emphasis in original).
20, 2012, Craig saw neurologist William R. Bauer, Ph.D.,
complaining of migraine headaches and chronic neck, mid and
low back pain with radiculopathy. Tr. 326. Craig reported
that his migraines had been causing more severe pain, but
they were further apart in time than previously. Tr. 326. He
described his pain as 3/10 with rest, 10/10 with activity,
and, at that visit, 8/10. Tr. 328. His pain decreased with
heat, rest, lying down, quiet, sitting, medication and
massage and increased with cold, activity, standing, and
walking. Tr. 328. Upon exam, he had decreased neck extension
with mild muscle tenderness in his trapezius and moderate
tenderness in his paracervical muscles, mild tenderness in
his thoracic spine, a labored range of motion in his lumbar
spine, and symmetrical decreased arm and leg strength. Tr.
328. Dr. Bauer diagnosed Craig with lumbar sprain and strain,
neck sprain and strain, back pain, and headache. Tr. 328. He
prescribed Ultram, Depakote, Vicodin, Topamax, Zanaflex,
Trileptal, and Flexeril. Tr. 328-329.
October 17, 2012, Craig returned to Dr. Bauer for a follow up
visit. Tr. 331. He reported that his pain level was a 9/10.
Tr. 331. He complained of headaches, back pain, muscle
cramps, muscle weakness, stiffness, and parasthesias. Tr.
332. Upon exam, he was in no acute distress. Tr. 332. He had
diminished reflexes and strength in his arms and legs and
positive straight leg raise tests. Tr. 333-334.
September 4, 2013, Craig had a lumbar spine x-ray taken. Tr.
396. The x-ray showed normal alignment, maintained disc
spaces, no evidence of spondylolysis or spondylolisthesis,
mild facet arthropathy at the L5-S1 level, and an osteophyte
arising from the superior lateral endplate of L4 on the left
at the L3-4 level. Tr. 396.
February 4, 2015, Craig visited general practitioner Eric G.
Prack, M.D., at the Fisher Titus Medical Center. Tr. 465.
Craig complained, among other things, of worsening bilateral
shoulder pain, left greater than right, worsening radicular
pain into his posterior legs, worsening headaches, and
numbness in his fingertips. Tr. 465.
March 17, 2015, Craig saw Adam J. Hedaya, M.D., at the pain
management clinic at the Fisher Titus Medical Center. Tr.
427-429. Craig complained of low and mid back pain, neck pain
and leg pain. Tr. 427. He rated his pain 9/10, described it
as sharp and achy, and stated that it got worse with sitting,
standing, walking, climbing the stairs, twisting, lifting,
pushing, pulling, and cold. Tr. 427. He also complained of
paresthesias in his bilateral thighs, feet, hands, and, at
times, his face. Tr. 427. Upon exam, Craig was alert,
oriented and attentive. Tr. 428. He had severe tenderness to
palpation over his lumbosacral spine and extension, flexion
and rotation aggravated his pain. Tr. 428. He had positive
straight leg raise testing, depressed reflexes symmetrically
in his knees and ankles, and no muscle atrophy,
fasciculations or spasms. Tr. 428. His cervical spine showed
positive facet loading maneuvers and some associated spasm
and some spasm in his thoracic spine. Tr. 428. He had no
radiculopathy in his upper extremities or thoracic areas or
signs of myelopathy. Tr. 428. Dr. Hedaya assessed Craig with
pain secondary to “posterior laminectomy syndrome with
possibly some associated lumbar neuritis, lumbar spondylosis,
” and neck pain which “may be secondary to
cervical spondylosis with some associated cervical
spasm.” Tr. 428. He ordered a lumbar MRI, a cervical
and lumbar x-ray, offered an epidural injection at the L5-S1
level, and prescribed Norco. Tr. 428.
April 22, 2015, Dr. Hedaya gave Craig a caudal epidural
steroid injection. Tr. 434.
5, 2015, Craig saw Dr. Hedaya again and reported some relief
from his injection. Tr. 430. He complained of parathesia in
multiple areas of his body and reported that the pain was
primarily in his head, 8/10. Tr. 430. He also reported pain
in his lower back and his neck and into his shoulders. Tr.
430. His lower back pain was greater on the right side and it
went down into his thigh and knee. Tr. 430. He reported,
“Medications and repositioning are helpful.” Tr.
430. He had not gotten his MRI or any of his x-rays. Tr. 430.
Dr. Hedaya again ordered imaging tests and stated that he
would re-evaluate after reviewing these. Tr. 430-431.
same day, Craig obtained x-rays of his spine. Tr. 436-437.
The results showed minimal marginal spurring at ¶ 3-4 in
his lumbar spine, mild thoracic spondylosis in his thoracic
spine, and a negative x-ray of his cervical spine. Tr.
19, 2015, Craig returned to Dr. Hedaya complaining of severe
pain, 10/10, described as stiff and throbbing and
“unbearable.” Tr. 432. His medication was
somewhat helpful. Tr. 432. He reported minimal relief from
the epidural injection, stated that he had not felt well
enough to start physical therapy, and reported that
“all areas of functioning are deteriorating.” Tr.
432. Upon exam, he was alert, oriented and attentive. Tr.
432. He had multiple tender points all over his body
“consistent with fibromyalgia picture.” Tr. 432.
He had tenderness over his cervical, thoracic and lumbar
muscles, depressed but symmetrical reflexes in his upper and
lower extremities, and an unremarkable gait and station. Tr.
432-433. After reviewing the recent x-rays and an MRI from
2010, Dr. Hedaya and assessed that Craig's “pain
picture may be secondary to cervical facet joint syndrome,
cervical spasm, cervicogenic headaches, ” and
“the possibility of thoracic spondylosis, lumbar
spondylosis, lumbar disc displacement.” Tr.
433. Dr. Hedaya saw “no imminent need for surgical
evaluation, ” and, instead of another injection,
preferred to see how Craig did after a course of physical
therapy. Tr. 433.
9, 2015, Craig returned to Dr. Eric Prack for a follow up
visit. Tr. 520. Craig reported being “very disappointed
in [his pain management] care.” Tr. 520. He stated that
his migraine headaches were well controlled by his
medication, but that his back injections tended to exacerbate
his migraine headaches. Tr. 520.
29, 2015, Craig saw Dr. Bauer for a follow-up after his pain
management referral. Tr. 574. Craig stated that he had
increased pain due to pain management taking him off all his
pain medications. Tr. 574. He rated his pain as 10/10, a 10
being the worst he has ever felt. Tr. 574. Upon exam, Craig
was in no acute distress and was oriented, awake and alert.
Tr. 575. He had tenderness at ¶ 5-S1 near his surgical
scar, a flattening of his lumbosacral curve, positive
straight leg raise testing, and reduced ankle reflexes. Tr.
576-577. He was restarted on Norco and Ultram. Tr. 577. Dr.
Bauer noted, “he is to recheck with [Bureau of
Vocational Rehabilitation] and if this fails he will be
looking at disability.” Tr. 577. Dr. Bauer wrote,
“functional capacity evaluation has significant
limitations.” Tr. 577.
September 4, 2015, more than a week after Craig's hearing
with the ALJ, Craig saw Amelia S. Prack, M.D., at Fischer
Titus Medical Care. Tr. 553-554. The reason for his visit was
for continuing difficulty with low back pain and his
application for disability. Tr. 552. Craig reported bilateral
numbness of his antero-lateral thighs, difficulty with
position changes due to low back pain, and an inability to
sit for more than 15-20 minutes. Tr. 552. He also reported
that lifting objects exacerbates his problems and that he is
limited to carrying relatively light objects. Tr. 552. He
reported no other lower extremity numbness and no lower
extremity weakness. Tr. 552. Upon exam, Dr. Prack noted that
Craig was in no apparent distress. Tr. 552. He had some
flattening of his lumbar spine, a well-healed surgical scar,
and no bony or muscle tenderness. Tr. 552. He had decreased
sensation in the front and side of his thighs but nowhere
else in his lower extremities, diminished or absent reflex in
the knees and ankles, and moderately limited range of motion
in his back in all planes. Tr. 553. She observed that he was
careful with position changes. Tr. 553.
Medical Opinion Evidence
Dr. Amelia Prack's opinion
September 4, 2015, the same day as his initial and only
visit, Dr. Amelia Prack completed a Medical Source Statement
on behalf of Craig. Tr. 550-551. Based on his reports of low
back pain, Dr. Prack opined that Craig could lift or carry
5-10 pounds occasionally, stand or walk for a total of
“perhaps 2” hours in a workday (and could do so
without interruption for a few minutes only), and could sit
“perhaps 2” hours in a workday (and could do so
without interruption for 15-20 minutes). Tr. 550. Based on
his decreased range of motion in his back and reported
increased low back pain, Dr. Prack found that Craig could
rarely climb, balance, stoop, crouch, kneel, crawl, reach,
push/pull, or use fine and gross manipulation. Tr. 550-551.
She assessed him with environmental restrictions due to an
increase in migraine headaches. Tr. 551. She opined that
Craig experiences severe pain that interferes with his
concentration, takes him off task, and causes absenteeism.
Tr. 551. Finally, Dr. Prack wrote that Craig would require
additional unscheduled rest periods during an eight hour
workday, stating, “sustained activity is not possible
for him.” Tr. 551.
Physical Therapist Melissa Shade's opinion
November 13, 2014, Craig saw physical therapist Melissa
Shade, P.T., for a functional capacity evaluation “to
determine his current physical tolerance in regards to
material and non-material handling activities and to assess
his ability to return to work.” Tr. 414. Craig reported
to Shade that his usual pain level is a 6/10 and that his
pain increased during the course of the 1-hour evaluation to
9/10. Tr. 916. The evaluation found the following: diminished
grip and pinch strength, trunk mobility limited by 50% in all
directions, and full range of motion of upper and lower
extremities with discomfort during some extension, flexion
and adduction. Tr. 415. Shade opined that Craig could
infrequently lift 5-10 pounds and carry 10 pounds; it was not
recommended that he bend, squat, stoop or kneel; he could
occasionally walk; could sit and stand for no more than 20
minutes before requiring a postural change; and could
occasionally push, reach and climb stairs. Tr. 415-416. Shade
opined that “any environmental conditions may be a
trigger for migraines” and that his migraines interfere