The opinion of the court was delivered by: DAVID G. TRAGER
In this social security disability benefits case, before the Court are plaintiff's and defendant's cross-motions for judgment on the pleadings. For the reasons which follow, the cross-motions for judgment on the pleadings are denied, and the case is remanded to the Administrative Law Judge (ALJ) for a determination consistent with this decision.
Plaintiff, Genevieve Rosario, is a 42 year-old woman with a high school equivalency diploma and 12 college credits. On June 9, 1989, plaintiff was injured in an automobile accident during the course of her employment as a nurse's aide. As a result of the accident, plaintiff sustained injuries to her neck, back, shoulders and legs.
On June 13, 1989, plaintiff was examined by her physician, Dr. Piontkowski, who found the following: 1) "paracervical spasm, moderate with limitation secondary to pain"; 2) "marked spasms" of the lower back; 3) mild to moderate degenerative changes over the superior aspect of the lumbosacral spine; 4) ecchymosis over the tibia and fibula of the left and right legs; 5) normal neurological examination of the upper extremities; and 6) positive straight leg raising to 50 degrees with normal neurological functioning of the legs. Dr. Piontkowski diagnosed plaintiff as having lower back derangement, sciatica and cervical sprain. In addition, he concluded that a herniated disc could not be ruled out. Plaintiff was advised to rest, take anti-inflammatory and muscle relaxant medication and to seek therapy with ultrasound, electrical stimulation and eventually exercise.
Plaintiff was examined by Dr. Donald Holzer, a neurologist, on July 19, 1989. Dr. Holzer found, among other things, a "moderate degree of paracervical muscle spasm with punch tenderness over the cervical spine and limitation of range of motion of the cervical spine ... in all directions." (Tr. at 94). Dr. Holzer's diagnosis was "cervical sprain, rule-out radiculopathy" and "lumbar sprain, rule-out radiculopathy." (Tr. at 95).
A CAT scan, MRI and EMG were performed at Dr. Holzer's recommendation. The MRI of plaintiff's spine, which was performed on October 10, 1989, was unremarkable. The CAT scan, performed on November 3, 1989, revealed a diffuse annular bulge at L4-L5 with mild compression on the anterior thecal sac. The EMGs and nerve conduction studies of plaintiff's lumbar and cervical spine were conducted on November 29, 1989 and December 11, 1989, respectively. Both were within normal ranges and showed no evidence of entrapment neuropathy or radiculopathy.
Plaintiff continued to see Dr. Holzer through August of 1990. Throughout that time, plaintiff's condition improved somewhat, but she continued to have neck, back, and leg pain. Dr. Holzer prescribed Amitriptyline, Midrin, and transcutaneous electrical nerve stimulation (TENS) (Tr. at 105).
On June 4, 1990, plaintiff returned to work as a nurse's aide for a period of three days. Plaintiff could not continue in this capacity as she experienced " recurrent pain in the neck and low back" when lifting a patient (Tr. at 108). Dr. Holzer examined plaintiff again on June 12, 1990, and reported that the examination revealed severe paracervical and paralumbar muscle spasm and tenderness. Plaintiff was to continue biofeedback and physical therapy in addition to using her TENS unit and was prescribed Soma compound (Tr. at 108).
At Dr. Holzer's request, plaintiff was examined by Dr. James Dana on August 21, 1990. Plaintiff complained of headaches, neck pain, low back pain, numbness and tingling in both legs and that her right leg "[gave] out" at times. Based upon his examination and the results of the MRI, CAT scan and EMGs, Dr. Dana diagnosed plaintiff as having cervical sprain, bilateral sacroiliac joint and ilio-lumbar ligament sprain, myofascial pain syndrome and bulging annulus at L4-L5. Dr. Dana recommended physical therapy, electrostim, trigger point therapy, a variety of massage therapies, hydrocortisone injections and a sacroiliac joint belt (Tr. at 121).
Dr. K. Seo, an orthopedic surgeon, conducted a consultative examination on behalf of the Social Security Administration (SSA) on September 10, 1990 (Tr. at 113-15). Based on his examination and plaintiff's medical records, Dr. Seo's impression was "status post [motor vehicle accident], cervical derangement with low back derangement" (Tr. at 115).
Plaintiff continued to see Dr. Dana through April 1991. During this period, Dr. Dana's diagnosis of August 21, 1990, remained unchanged except for an additional diagnosis of nerve root irritation at C8 (Tr. at 117-130). On April 16, 1991, Dr. Dana completed a disability certificate, presumably for plaintiff's workers' compensation benefits, which indicated that plaintiff was "totally incapacitated" from June 9, 1989, to that date. (Tr. at 122). On April 25, 1991, Dr. Dana completed a medical assessment of plaintiff's ability to perform work-related activities, at SSA's request, which stated that plaintiff had the capacity to lift up to 10 pounds, stand/walk for a total of 2-3 hours per day, 1/2 hour without interruption, and sit a total of 8 hours per day, 1 hour without interruption. (Tr. at 123-25).
Plaintiff applied for disability benefits on April 7, 1990. Her initial application was denied on September, 28, 1990. Reconsideration of the ...