United States District Court, N.D. Indiana, Fort Wayne Division
KENNETH R. NUCKOLS Plaintiff,
CAROLYN W. COLVIN, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION Defendant.
OPINION AND ORDER
RUDY LOZANO, JUDGE UNITED STATES DISTRICT COURT
This matter is before the Court for review of the Commissioner of Social Security’s decision denying Disability Insurance Benefits to Plaintiff, Kenneth R. Nuckols. For the reasons set forth below, the decision of the Commissioner is REVERSED and this case is REMANDED to the Social Security Administration for further proceedings consistent with this opinion pursuant to sentence four of 42 U.S.C. section 405(g).
On October 22, 2010, the Plaintiff, Kenneth Nuckols, filed an application for Disability Insurance Benefits (“DIB”). Nuckols alleged that his disability began on August 8, 2009, due to a fractured back (requiring spinal fusion), a titanium rod that ran from his knee to his ankle, sleep apnea, emphysema, left shoulder problems, and high blood pressure. (Tr. 20, 181). The Social Security Administration denied his initial application and also denied his claims on reconsideration. On March 16, 2012, the Plaintiff appeared with counsel, Mark Mora, at an administrative hearing before Administrative Law Judge (“ALJ”) Warnecke Miller (“Miller”). (Tr. 35-70). Testimony was provided by Nuckols and Marie Kieffer (a vocational expert or “VE”). (Tr. 35-70). On June 6, 2012, ALJ Miller denied the claimant’s DIB claim, finding that Nuckols was not disabled because he could perform a significant number of jobs in the national economy, despite his limitations. (Tr. 20-29).
On June 29, 2012, Nuckols requested that the Appeals Council review the ALJ’s decision and the request was denied on July 19, 2013. (Tr. 1). Accordingly, the ALJ’s decision became the Commissioner’s final decision. See 20 C.F.R. § 422.210(a)(2005). The claimant has initiated the instant action for judicial review of the Commissioner’s final decision pursuant to 42 U.S.C. § 405(g).
Nuckols was born on October 10, 1958. (Tr. 27). Nuckols alleges the following impairments: fractured back that required spinal fusion, titanium rod from knee to ankle, sleep apnea, emphysema, left shoulder problems, and high blood pressure. (Tr. 181). Nuckols has at least a high school education and is able to communicate in English. (Tr. 28). In the past fifteen years, Nuckols has worked as a metal products fabricator. (Tr. 27, 42-44).
The medical evidence can be summarized as follows:
Prior to his alleged onset date of August 8, 2009, Nuckols’ primary care physician, Dr. Thomas M. Lee, on June 16, 2008, diagnosed him with degenerative disk disease and degenerative joint disease and noted that the pain medication Tramadol was not working. (Tr. 291). By October 31, 2008, Dr. Lee noted increased back pain with right radicular leg pain. (Tr. 289). Nuckols worked for the next six months and while working on May 13, 2009, suffered an injury resulting in severe back pain, which led to an emergency room visit. (Tr. 246).
Nuckols attempted physical therapy from May 27, 2009, through June 3, 2009. (Tr. 247). On July 21, 2009, an MRI of the lumbar spine confirmed the following:
1. Multilevel degenerative lumbar spondylosis [;…] Grade 1 Spondylolisthesis of L5 on S1; Severe L2-3 disc narrowing with mild central canal stenosis.
2. Large left paracentral T10-T11 disc herniation or spinal stenosis and encroachment on the thoracic cord; 3. Findings suspicious for right lateral L5-S1 disc protrusion with encroachment on the right L5-S1 neural foramen […]
Dr. Lee prescribed morphine sulfate to address the increased pain. (Tr. 289). At the May 8, 2009, August 14, 2009, and November 13, 2009, visits, Dr. Lee upgraded Nuckols back pain to chronic and continued to refill the morphine sulfate prescription. (Tr. 286-88). The morphine was supplemented with Tramadol at the August visit. (Tr. 287). On April 9, 2010, his neurosurgeon, Dr. Juluis Silvidi, fine-tuned the diagnosis (Right L5 radiculopathy with motor and sensory deficit and L5 spondylosis with spondylolisthesis and right-sided foraminal disc protrusion). (Tr. 267). Then Dr. Silvidi performed an L5 Gill laminectomy with L5-S1 spinal fusion on April 9, 2010 (Tr. 302-304). On July 31, 2010, Dr. Silvidi released him back to work, warning him of the potential for L4-L5 deterioration in the future. (Tr. 304). Nuckols, at the time, also reported relief of right leg pain that was present preoperatively, with less residual back pain and had been physical active at home involving some tree trimming. Id.
In August 2010, Nuckols returned to work but was unable to continue after about three weeks due to back pain issues and pain medication concerns. (Tr. 56-57). On December 13, 2010, a State Agency consultative examiner, Dr. Melanie Gatewood, noted that Nuckols had “pulling” back pain during straight-leg-raise testing. (Tr. 324). Post-surgery radiographs, taken on December 13, 2010, by Dr. Joseph Gaddy, revealed L5-S1 spondylolisthesis, L4-L5 facet arthropathy, discogenic degenerative changes with narrowed interspaces at L2-L3, and mild dextroscoliosis. (Tr. 328). Dr. Gaddy identified range of motion deficits in the lumbar spine in relation to forward flexion, extension, and lateral flexion. (Tr. 326). Nuckols testified about significant back pain that was aggravated by activity, interfered with his sleep and persisted despite treatment with pain medication. (Tr. 47-48, 51, 59). The pain medication caused nausea and drowsiness, requiring Nuckols to take naps and to limit head movement during periods of nausea. (Tr. 61).
In May 2011, Nuckols sought emergency room treatment for right foot pain after falling off his motorcycle. He was described as alert, oriented, and cooperative and exhibiting appropriate mood and affect. (Tr. 351-67).
Thoracic Spine and Cervical Spine
Nuckols also testified that he suffered from mid-back pain. (Tr. 47). The MRI taken on July 21, 2009, identified a large left paracentral T10-T11 disc herniation or spinal stenosis and encroachment on the thoracic cord. (Tr. 250). These thoracic spine problems have not been surgically addressed, but Dr. Silvidi emphasized their seriousness by assigning a whole person permanent partial impairment rating of 8% according to the AMA Guidelines. (Tr. 303). On examination December 13, 2010, the examining physician identified range of motion deficits in the cervical spine in relation to flexion, extension, and lateral flexion. (Tr. 326).
Nuckols described left shoulder problems that originated from an old motorcycle accident, causing his shoulder to pop out of socket and cause intense pain (Tr. 55-56). Despite the persistence of this problem over the years, Nuckols continued to work. Id. Dr. Gaddy, the State Agency consultative examiner, identified range of motion deficits in the left shoulder in relation to abduction, forward elevation, and internal rotation. (Tr. 326). Dr. Gaddy also identified right shoulder ...