United States District Court, S.D. Ohio, Western Division, Dayton
NEIL L. RANLY, Plaintiff,
COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.
DECISION AND ENTRY
L. Ovington United States Magistrate Judge.
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.
Plaintiff and His Lumbar Spine Problems
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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,
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.
January 2013, Dr. Minella noted, “Seven months post op,
coping well, with some leg dysesthesias. 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
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
Plaintiff's Cervical Spine
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 ¶ 4-C5 and