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Craig v. Commissioner of Social Security Administration

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

August 25, 2017



          Kathleen B. Burke, United States Magistrate Judge.

         Plaintiff 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.

         For the reasons stated below, the decision of the Commissioner is AFFIRMED.

         I. Procedural History

         Craig 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.

         II. Evidence

         A. Personal and Vocational Evidence

         Craig 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.

         B. Relevant Medical Evidence

         An MRI 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.

         In the 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.

         On 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).

         On July 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.

         On 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.

         On 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.

         On 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.

         On 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.

         On April 22, 2015, Dr. Hedaya gave Craig a caudal epidural steroid injection. Tr. 434.

         On May 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.

         The 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. 436-437.

         On May 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.

         On June 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.

         On June 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.

         On 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.[1] 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.

         C. Medical Opinion Evidence

         1. Dr. Amelia Prack's opinion

         On 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.

         2. Physical Therapist Melissa Shade's opinion

         On 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 ...

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