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Griffith v. Astrue

March 30, 2009

ANTOINETTE MARIE GRIFFITH, PLAINTIFF
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Charles J. Siragusa United States District Judge

DECISION AND ORDER

INTRODUCTION

This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner of Social Security ("Commissioner" or "Defendant"), which denied plaintiff Antoinette Marie Griffith's ("Plaintiff") application for disability insurance and supplemental security income benefits. Now before the Court is Defendant's motion for judgment on the pleadings [#7], and Plaintiff's cross-motion for an order reversing Defendant's decision and remanding the matter for calculation of benefits [#8], or, in the alternative, remanding the case to a new administrative law judge. For the reasons that follow, Defendant's application is denied, Plaintiff's application is granted in part, and this matter is remanded for further administrative proceedings.

PROCEDURAL HISTORY

On June 2, 2004, Plaintiff applied for disability and supplemental security income benefits, claiming to be disabled due to back pain. (90).*fn1 With regard to disability benefits, Plaintiff remained insured through December 31, 2008. (12). The alleged onset date of Plaintiff's disability was September 1, 2003, when she was involved in a motor vehicle accident. (90). The Commissioner denied Plaintiff's application, and she requested a hearing before an administrative law judge ("ALJ"). On March 21, 2007, a hearing was held before ALJ Bruce Mazzarella. On April 26, 2007, the ALJ issued a decision denying benefits, finding that Plaintiff could perform her past relevant work as a collections agent, since she had the residual functional capacity (RFC) to perform sedentary work. (15-21). On November 16, 2007, the Appeals Council denied Plaintiff's request for review. (5-8). On January 2, 2008, Plaintiff commenced the subject action.

VOCATIONAL HISTORY

Plaintiff was forty-nine years of age at the time of the hearing, and had completed high school and some vocational training in mechanical drafting. (380, 389-90). Her employment history included work as a factory worker making baseball caps and electrical alternators, a deli worker, and a plant nursery employee. (90). Plaintiff also worked as a collection agent from September 2000 until June 2001, when she was fired from the position, because she "couldn't perform the job." (48). It is unclear why Plaintiff could not perform the job, although the reason apparently had nothing to do with her alleged disability.

MEDICAL EVIDENCE

Plaintiff's medical history was summarized in the parties' submissions and need not be repeated here. It is sufficient for purposes of this Decision and Order to note the following facts.

In November 1997, Plaintiff's primary care doctor, Timothy Siepel, M.D. ("Siepel") reported that Plaintiff had "a history of persistent lower back pain with radiculopathy." (197). An x-ray of Plaintiff's lumbosacral spine showed disc space narrowing at L4-5 and L3-4. A CT scan of the spine showed "diffuse disc bulge at L4-5 which flattens the anterior thecal sac. This is combined with mild bilateral ligamentum flavum hypertrophy which may result in some degree of lateral recess stenosis [narrowing]." (197).

On September 1, 2003, Plaintiff was injured in a motor-vehicle accident, in which her vehicle was rear ended, pushed into the path of an oncoming car, and then struck again on the left passenger side. As a result, Plaintiff suffered a concussion, with loss of consciousness, along with neck and back pain. Plaintiff's neck pain eventually resolved, however, her back pain persisted.

On March 24, 2004, Siepel referred Plaintiff to Naren Kansal, M.D. ("Kansal"), a neurologist. Plaintiff told Kansal, with regard to her back pain, that "sitting is the worst position,"and that although she initially had pain radiating into her left leg, with numbness in her left big toe, the leg pain had subsided, but the numbness remained. (273). Kansal examined Plaintiff and stated that Plaintiff's lumbar spine was normal, with no paraspinal spasm, although there was pain at the lumbosacral junction area and some tenderness. (274). Kansal's impression was "left lumbar radiculopathy*fn2 , etiology undetermined." (274).

On August 6, 2004, Plaintiff was examined by Mohammad Jaffri, M.D. ("Jaffri"), a non-treating consultative examiner. At that time, Plaintiff was complaining of "constant" low back pain, with numbness in her left big toe. (290). Plaintiff stated that "sitting or standing for 10 minutes aggravate[d] the pain," and that she became tired after walking for more than five minutes. (290). Jaffri summarized Plaintiff's MRI scans as showing "disk degeneration at L3-4 with marked collapse," "broad annular bulge at L3-4 with mild central canal stenosis," "annular bulge at L4-5," and "eccentric nerving of the left neural foramen." (290). Plaintiff indicated to Jaffri that she cooked meals, and performed shopping once a week, but did no cleaning or laundry, due to pain. On physical exam, Jaffri observed that Plaintiff had difficulty walking heel to toe and difficulty squatting, and that Plaintiff had "mild spinal tenderness and muscle spasm in the low back," but "no SI joint or sciatic notch tenderness." (292). Jaffri's diagnosis, in relevant part, was "history of motor vehicle accident with resultant lower back pain. MRI of the lumbar spine showing disk degeneration L3-4 with marked collapse and also mild central canal stenosis [narrowing] L3-4, and annular bulge at L4-5 narrowing left neural foramen [tunnel]." (292). Jaffri concluded that Plaintiff would have the following limitations: "Moderate limitations with lifting and carrying heavy weights around. Moderate limitation with prolonged standing and walking. Mild limitation with prolonged sitting. Mild limitation with pushing or pulling." (292). Jaffri did not quantify, in hours, the terms "moderate" and "mild."

On August 19, 2004, Kansal examined Plaintiff, and reported that, "[c]linically, she is just not any better." (311). Kansal stated that recent EMG and nerve conduction studies were "completely normal." (311). Such negative test result did not, however, cause Kansal to doubt that Plaintiff was experiencing low back pain, or cause him to rule out spinal stenosis as the cause. (309). At that time, Kansal concluded that Plaintiff's "best option will be to consider epidural steroids." (311).

On March 9, 2005, Kansal examined Plaintiff and stated that Plaintiff was still complaining of back pain, though her legs were "feeling fine." (309). On physical examination, Kansal observed "tenderness of both the lumbosacral junction area as well as some of the sacroiliac joint." (309). Kansal stated that it was "conceivable" that Plaintiff's spinal stenosis at L3-L4 was causing the pain. Kansal indicated that Plaintiff could pursue chiropractic treatment, or possibly surgery, consisting of "decompressive lumbar laminectomy." (309).

On July 14, 2005, Siepel examined Plaintiff, who was complaining of low back pain, with occasional pain into the left leg. (346). Siepel's assessment was herniated disc (L3-L4), lumbar canal stenosis, and sciatica, left L4. (346). Siepel referred Plaintiff for physical therapy, and noted that a previous epidural steroid injection had been "uncomfortable, and not very effective." (346).

On July 17, 2006, at Siepel's request, Plaintiff had an MRI test, which showed, inter alia, "severe degenerative disk disease and annular bulging leading to [moderate to severe] spinal canal stenosis at L3-4," and "small left paracentral disk herniation at L4-5 with compromise of the left L4 neural foramen." (198).

On August 2, 2006, Siepel examined Plaintiff and observed that her "thoracolumbar spine motion was abnormal." (178). His assessment was herniated disc (L3-L4) and lumbar canal stenosis. Plaintiff indicated that she did not want surgery, because of its risks, but Siepel "warned her [that] she may not improve with time." (178).

On September 13, 2006, Siepel completed an RFC assessment form. (173-177). Siepel stated that Plaintiff could lift and carry up to five pounds occasionally, and never more than that. (173). Siepel stated that Plaintiff could sit for fifteen minutes at a time without interruption, and for four hours in an eight-hour workday. Siepel stated that Plaintiff could stand for fifteen minutes at a time without interruption, and for two hours total in an eight-hour workday. Siepel stated that Plaintiff could walk for fifteen minutes at a time without interruption, and for two hours total in an eight-hour workday. (174). Siepel indicated that he based his opinions regarding sitting, standing, and walking on Plaintiff's "statement of her experience." (174). Siepel further stated that Plaintiff could never climb, stoop, crouch, kneel, or crawl, and that he based that opinion on Plaintiff's ...


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