United States District Court, W.D. Arkansas, Fayetteville Division
DAVID M. SELF PLAINTIFF
NANCY A. BERRYHILL, Acting Commissioner, Social Security Administration DEFENDANT
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
David M. Self, brings this action pursuant to 42 U.S.C.
§ 405(g), seeking judicial review of a decision of the
Commissioner of the Social Security Administration
(Commissioner) denying his claims for a period of disability
and disability insurance benefits (DIB) and supplemental
security income (SSI) under the provisions of Titles II and
XVI of the Social Security Act (Act). In this judicial
review, the Court must determine whether there is substantial
evidence in the administrative record to support the
Commissioner's decision. See 42 U.S.C. §
protectively filed his current applications for DIB and SSI
on October 22, 2015, alleging an inability to work since July
3, 2014, due to neck problems, including surgery; carpal
tunnel in his left hand; enlarged prostate; numbness in his
arms, hands and feet; a cyst on his left wrist; a pinched
nerve that impacts both arms and both feet; and a spot on his
left lung. (Tr. 203-204, 214-215, 227-228, 239-240). For DIB
purposes, Plaintiff maintained insured status through
December 31, 2019. (Tr. 203, 214, 227, 239). An
administrative hearing was held on September 1, 2016, at
which Plaintiff appeared and testified. (Tr. 172-200).
Plaintiff's counsel was present, and Barbara Hubbard
(VE), was also present and testified. (Tr. 172-200).
written opinion dated November 23, 2016, the ALJ found that
the Plaintiff had a severe impairment of residuals of
injuries received in a four-wheeler accident and herniated
nucleus pulposus at C3-4, C4-5, and C5-6 status post
laminectomy and fusion. (Tr. 97). However, after reviewing
the evidence in its entirety, the ALJ determined that the
Plaintiff's impairments did not meet or equal the level
of severity of any listed impairments described in Appendix 1
of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr.
97-98). The ALJ found Plaintiff retained the residual
functional capacity (RFC) to perform light work, except that
he was limited to occasional overhead reaching with his
non-dominant hand. (Tr. 98-104). With the help of VE
testimony, the ALJ determined that Plaintiff was unable to
perform his past relevant work as a welding machine tender
and pipefitter. (Tr. 104). However, based on the
Plaintiff's age, education, work experience, and RFC, the
ALJ determined that there were jobs that existed in
significant numbers in the national economy that the
Plaintiff could perform, such as a cashier, a marking clerk,
and a routing clerk. (Tr. 105). Ultimately, the ALJ concluded
that the Plaintiff had not been under a disability within the
meaning of the Social Security Act from July 3, 2014, through
the date of the decision. (Tr. 105).
then requested review of the hearing decision by the Appeals
Council, which after reviewing additional evidence submitted
by Plaintiff, denied that request on October 18,
2017. (Tr. 1-7). Plaintiff filed a Petition for
Judicial Review of the matter on December 18, 2017. (Doc. 1).
Both parties have submitted briefs, and this case is before
the undersigned for report and recommendation. (Docs. 12,
Court has reviewed the transcript in its entirety. The
complete set of facts and arguments are presented in the
parties' briefs and are repeated here only to the extent
hearing before the ALJ on September 1, 2016, Plaintiff
testified that was born in 1963, and his past relevant work
consisted of work as a welding machine tender, a material
cutter, and a pipefitter. (Tr. 104, 177, 198).
to the relevant time period, Plaintiff was treated generally
for right ear pain, hearing issues, a cyst of his earlobe,
right hip pain, a groin abscess, and gastroenteritis. (Tr.
460, 463, 466, 468-469). Also prior to the relevant time
period, in April 2014, Plaintiff was treated in the emergency
room immediately following an All-Terrain Vehicle accident
and then at Boston Mountain Rural Health Center for
complications from that accident. (Tr. 457). Six weeks
following the accident on June 3, 2014, Plaintiff's
cervical spine x-ray showed moderate chronic degenerative
disc disease and spondylosis at C5-6 without significant
change; interval development of mild degenerative disc
disease; and minimal spurring at C4-5. (Tr. 472). On June 6,
2014, Plaintiff visited Boston Mountain Rural Health Center
for follow-up after his ATV accident. (Tr. 454). He was
assessed with cervical pain, bilateral shoulder pain, and
left wrist pain. (Tr. 455). Plaintiff refused a MRI of his
cervical spine, and x-rays of his shoulders and left wrist
were negative. (Tr. 454-456).
review of the medical evidence reflects that one year after
the relevant time period began, Plaintiff was seen at Boston
Mountain Rural Health Center on June 2, 2015, for complaints
of not sleeping well, pain in his left wrist from his
accident the previous year, and bumps on his head. (Tr. 451).
Upon examination, his gait was steady, he had no edema, and
he had normal sensation and strength. (Tr. 452). Plaintiff
was assessed with sleep disturbance, erectile dysfunction,
and chronic pain. (Tr. 453). Gina Dickey, APRN, noted that
Plaintiff's medications were adjusted. (Tr. 453).
15, 2015, Plaintiff saw Dr. Noel Henley at Ozark Orthopaedics
for left wrist pain. (Tr. 482). Clinic notes indicated that
the pain was from his ATV accident in 2014. (Tr. 482). Clinic
notes also indicated that Plaintiff had so many complaints
that “[i]t was almost impossible” to narrow them
down. (Tr. 482). Dr. Henley noted that the four views of the
left wrist that day revealed no fracture, dislocation, or
other abnormality or sign of acute injury. (Tr. 482). He was
diagnosed with possible carpal tunnel syndrome. Dr. Henley
instructed Plaintiff to wear a splint on the wrist and to
undergo nerve testing. (Tr. 483).
22, 2015, Plaintiff underwent an electrodiagnostic testing by
Dr. Miles Johnson for his neck and left upper extremity pain,
numbness, tingling and weakness. (Tr. 490). Dr. Johnson's
notes indicated that plaintiff was a smoker. (Tr. 491). The
testing was consistent with a diagnosis of cervical
radiculopathy at C 6 and/or C7 (left); mild left median
neuropathy at the level of the wrist consistent with a
diagnosis of carpal tunnel syndrome; and history and physical
examination was also suggestive of possible cervical
myelopathy. (Tr. 491). Dr. Johnson recommended a MRI of the
cervical spine to further evaluate the neck pain. (Tr. 492).
15, 2015, Plaintiff had a MRI of his cervical spine, which
showed extensive multilevel cervical spondylosis, worse at
the C3-4, C4-5, C5-6 levels with moderate canal stenosis at
these levels and moderate to severe bilateral foraminal
stenosis. (Tr. 488). It also showed T2 hyperintensity within
the cord at the C4-5 and C5-6 levels compatible with edema or
gliosis. (Tr. 488).
23, 2015, Plaintiff saw Dr. John Barr with complaints of arm
contractures and hand weakness, greater on the left than the
right, worsening gait and balance, burning pain over entire
left arm, and difficulty holding his left arm straight
especially with intended motion. (Tr. 546). Dr. Barr
recommended a three-level anterior cervical discectomy and
fusion procedure (ACDF) and emphasized smoking cessation for
successful bone fusion. (Tr. 547).
August 6, 2015, Plaintiff saw Dr. Barr, who determined that
based on Plaintiff's severe stenosis at C4-5 and moderate
to severe at C3-4, Plaintiff should undergo ACDF for direct
decompression of the cervical cord. (Tr. 150, 525). Plaintiff
was admitted to Washington Regional Medical Center for an
ACDF procedure at C3 through C6. (Tr. 147, 522). A MRI on
that date showed C3 through C6 anterior cervical fusion with
good anatomic alignment and hardware intact. (Tr. 151, 529).
Plaintiff's chest x-ray was also normal. (Tr. 155, 533).
Plaintiff was admitted to Washington Regional Medical Center
after his evaluation and underwent a C3-4, C4-5 and C5-6 ACDF
procedure. (Tr. 523, 526). Upon discharge from Washington
Regional Medical Center on August 6, 2015, Plaintiff was
instructed to do light work with no heavy lifting or
straining and to wear his cervical collar at all times. (Tr.
August 27, 2015, Dr. John Barr completed a Medical Source
Statement, wherein he opined that Plaintiff could: frequently
lift and/or carry less than ten pounds; occasionally lift
and/or carry less than ten pounds; stand and/or walk a total
of four to six hours; sit a total of eight hours; limited
pushing and/or pulling in upper and lower extremities; five
or more breaks in an eight-hour day; avoidance of exposure to
extreme heat, wetness, fumes, odors, dusts, gases, poor
ventilation, and hazards; and avoidance of concentrated
exposure to humidity. (Tr. 499-501). Plaintiff also had an
office visit with Dr. Barr that day and Dr. Barr noted that
Plaintiff's left arm was no longer in the flexed position
and had improved range of motion; he had improved strength;
he had continued numbness but his dysphagia was resolving; he
denied significant neck pain; and he was healing well. (Tr.
September 30, 2015, an x-ray of Plaintiff's cervical
spine showed cervical spine fixation from C3 through C6
anteriorly with plate and screws, and no hardware loosening
or fracture. (Tr. 156, 521).
October 1, 2015, Plaintiff saw Dr. Barr for his first
post-operative evaluation. Dr. Barr noted that Plaintiff had
improved and was fully functioning up until two weeks prior
when he was engaged in heavy lifting, which caused a setback
with muscle aches and pains in his biceps. (Tr. 541). Dr.
Barr ordered an ...