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Ranly v. Commissioner of Social Security Administration

United States District Court, S.D. Ohio, Western Division, Dayton

June 25, 2019

NEIL L. RANLY, Plaintiff,


          Sharon L. Ovington United States Magistrate Judge.

         I. Introduction

         This social security case is was previously remanded to the Social Security Administration under the sixth sentence of 42 U.S.C. § 405(g) for further proceedings in light of new and material evidence concerning Plaintiff's impairments. On remand, Administrative Law Judge Eric Anschuetz issued a decision concluding that Plaintiff was not under a disability and, therefore, not eligible to receive Supplemental Security Income or Disability Insurance Benefits. Plaintiff has returned to this Court contending that ALJ Anschuetz erred by failing (1) to credit the opinions of his long-term treating neurosurgeon Dr. Minella, (2) to find that his carpal tunnel syndrome constitutes a severe impairment, and (3) to properly measure his credibility. The Commissioner finds no error in, and substantial evidence supporting, the ALJ's decision and, therefore, seeks an Order affirming his decision.

         II. Background

         A. Plaintiff and His Lumbar Spine Problems

         Plaintiff asserts that he has been under a “disability” since September 16, 2011. He was 35 years old on that date and was therefore considered a “younger person” under Social Security Regulations. He is high-school graduate and has worked in the past as a laborer, a machinist, on truck driver, and a warehouse driver.

         An EMG on August 23, 2010 showed Plaintiff had mild chronic L5-S1 radiculopathy on the right. Beginning in September 2010, neurologist Dr. Krousgrill examined Plaintiff for lumbar and cervical spine impairments. She diagnosed Plaintiff with L5-S1 radiculopathy, right L5-S1 neural foraminal stenosis, and lumbar arthritis. She prescribed medication, physical therapy, TENs unit and ultrasound. (Doc. #4, PageID #s 829-30).

         On five occasions between September 2010 and November 2010, emergency room physicians evaluated and treated Plaintiff with pain medication for chronic uncontrolled back pain with related lower extremity. Examinations revealed tenderness to palpation along his lumbar and sacroiliac areas, decreased range of motion, and positive straight-leg raises. Id. at 581, 598, 602.

         An October 2010 MRI of Plaintiff's lumbar spine showed disc bulges at ¶ 3-L4 and L4-L5 and L5-S1; central canal stenosis at ¶ 3-L4; and at ¶ 5-S1 questionable left S1 nerve root contact as well as foraminal narrowing. Id. at 520-21.

         In November 2010, interventional radiologist, Dr. Syed, evaluated Plaintiff for severe low back pain with radiation into bilateral lower extremities. Upon examining Plaintiff, Dr. Syed noted positive straight-leg raises and Fabere Maneuver, bilaterally. He treated Plaintiff with a series of epidural steroid injections under fluoroscopic guidance. Id. at 529-30, 533-34.

         Also in November 2010, orthopedist Dr. Hoskins evaluated Plaintiff for right-sided low-back pain and associated lower-extremity symptoms. He referred Plaintiff to a pain-management specialist and physical therapy. Id. at 642-44.

         In mid-November 2010, Plaintiff first saw neurosurgeon Dr. Minella for surgical consultation. Dr. Minella noted decreased pinprick in a right C6-C7 distribution, but he thought that Plaintiff was not “a great surgical candidate” because he had too many symptoms and recommended pain management. Id. at 701.

         In late December 2010, a pain-management specialist, Dr. Mathai, initially examined Plaintiff for low-back pain and right-leg symptoms. She assessed Plaintiff with displacement of his lumbar spine and degeneration of his lumbar discs at multiple levels. Id. at 800-02. In her subsequent examinations through May 2011, Dr. Mathai noted decreased and painful lumbar range of motion with tenderness, antalgic gait, positive bilateral straight leg raises and hyperpathia, right more than left, and sacroiliac joint tenderness. Id. at 787, 797, 801.

         Dr. Mathai diagnosed displaced lumbar disc, multilevel lumbar degenerative disc disease and possible peripheral neuropathy. Id. at PageID#801; see PageID#s 787, 797. Dr. Mathai performed several procedures between December 2010 and June 2011, including lumbar-epidural blocks, right sacroiliac-joint injections, right, and bilateral-facet blocks. Some helped temporarily, but all failed to provide Plaintiff with ongoing relief. Id. at 788-98, 894.

         In March 2011, a lumbar MRI showed disc bulges at ¶ 11-12, L2-3, L3-4, L4-5 (with central annular tear) and L5-S1; lateral or central canal stenosis at ¶ 11-12, L3-4, L4-5 and L5-S1 (with material approaching the left S1 nerve root); hypertrophic changes between L1-2, and L5-S1; and foraminal narrowing between L2 and L5. Id. at 1149. A radiologist diagnosed Plaintiff with multi-level spondylosis most severe at ¶ 3-4, L4-5 and L5-S1. Id.

         In late March 2011, Plaintiff again saw Dr. Minella for low-back and bilateral-leg pain, right more than left. Dr. Minella explained, “Certainly a fusion could be done from L3 to the sacrum, however I certainly could not guarantee that this would get rid of all his symptoms. I would be concerned that he might feel that he's worse than he was previously. Therefore I cannot strongly recommend surgery.” Id. at 893.

         When Plaintiff saw Dr. Minella in December 2011, he reported that his symptoms had “worsened, as they were mild and now are described as unbearable ….” with pain, numbness and tingling. Id. at 1053. On examination, Dr. Minella noted decreased sensation of both legs in an L3, L4, L5 distribution. They discussed surgery-a fusion from L3-S1. Plaintiff decided to proceed with the surgery.

         In April 2012, before Plaintiff underwent surgery, an MRI showed “no substantial change” compared to his previous MRI (taken on March 22, 2011). Id. at 1044-45. Also at this time, Dr. Minella completed a “Short Work Questionnaire” indicating that Plaintiff, at most, could perform part-time sedentary work. Id. at 1157-58.

         On June 7, 2012, Dr. Minella, performed a laminectomy of L3, L4 and L5 and fusion with rod and screw fixation. Diagnoses at that time included lumbar radiculopathy, chronic back and bilateral leg pain (left more than right), lumbar stenosis, and surgical instability. Id. at 1073-1086, 1093-1102.

         On June 12, 2012, Dr. Minella documented Plaintiff's post-operation status, writing: “On exam today, he states he doesn't feel too bad. He has some right leg pain. His incision is healing well and we removed staples. At this point, he will continue his recovery and return to my office in four weeks for reevaluation.” Id. at 1161. On July 18, 2012, Dr. Minella again saw Plaintiff and explained, “He is doing well. Sitting does cause him some leg pain….” Id. at 1160. Dr. Minella next saw Plaintiff on September 19, 2012. Dr. Minella reported, “He states overall he feels good, other than some pain when sitting. I reviewed his lumbar spine x-ray today which looks good. He may continue the brace at this time and return to my office in three months for reevaluation.” Id. at 1159.

         In January 2013, Dr. Minella noted, “Seven months post op, coping well, with some leg dysesthesias.[1] He will continue on Tramadol and Robaxin….” Id. at 1185 (footnote added). In June 2013, Mr. Ranly reported right leg pain for the past week, although better, it was still at a pain level of 5/10. Id. at 1214. Upon inspection and palpation, Dr. Minella observed that Plaintiff's “muscle tone [was] equal, without atrophy, without spasticity, no abnormal movement. Id. at 1216. He noted that lumbar spine x-rays on May 5, 2013 were “ok.” Id. Nevertheless, Dr. Minella recognized that Plaintiff remained in pain (again, 5/10) and he referred Plaintiff to pain management. Id. at 1214, 1217.

         On November 11, 2015, Mr. Ranly was treated for back pain at the emergency room. Treatment notes relate that his pain “is moderate in degree and in the area of the right lower lumbar spine and right SI joint and radiation to the right lower extremity.” Id. at 1652. He was diagnosed with “chronic nontraumatic lumbar back pain associated with muscle strain.” Id. at 1653. He was discharged home with prescriptions for Toradol and Norflex.

         B. Plaintiff's Cervical Spine

         In August 2010, a cervical-spine MRI found mild central stenosis at ¶ 4-C5, C5-C6 and C7-T1. Joint arthropathy resulted in bilateral foraminal narrowing at ¶ 4-C5 and C5-C6. And straightening of the normal cervical lordosis was noted due to either muscle spasm versus positioning. Id. at 523-24. Upon consultation in November 2010, radiologist Dr. Syed reported that Plaintiff's August 2010 MRI of his cervical spine without IV contrast “demonstrates mild degenerative disc disease at ¶ 4-C5 as well as C7-T1 with mild central stenosis at these levels….” Id. at 533. Dr. Syed also noted that Plaintiff had mild bilateral foraminal narrowing at ΒΆ 4-C5 and moderate ...

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