United States District Court, E.D. Arkansas, Northern Division
SUMMER A. HORNBAKER PLAINTIFF
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT
MEMORANDUM OPINION AND ORDER
Plaintiff
Summer A. Hornbaker (“Hornbaker”) began the case
at bar by filing a complaint pursuant to 42 U.S.C. 405(g). In
the complaint, she challenged the final decision of the
Acting Commissioner of the Social Security Administration
(“Commissioner”), a decision based upon the
findings of an Administrative Law Judge (“ALJ”).
Hornbaker
maintains that the ALJ's findings are not supported by
substantial evidence on the record as a whole.[1] Hornbaker so
maintains because her residual functional capacity was
erroneously assessed.[2] Because it is not clear how the ALJ could
weigh the medical opinions as he did in making the
assessment, a remand is warranted.
Hornbaker
alleged in her applications for disability insurance
benefits, supplemental security income payments, and disabled
widow's benefits that she became disabled in January of
2014. She alleged that she became disabled, in part, because
of back pain and chronic obstructive pulmonary disease
(“COPD”).
The
record reflects that in April of 2013, Dr. Mark Tait, MD,
(“Tait”) performed a consultative examination of
Hornbaker. See Transcript at 542-544. He diagnosed
her with low back pain with mild to moderate degenerative
joint disease in the lumbar portion of her spine.
On June
23, 2015, Dr. Shannon Brownfield, MD,
(“Brownfield”) performed a consultative
examination of Hornbaker. See Transcript at 668-672.
Although his penmanship is difficult to decipher, he appears
to have found that she had a full range of motion in her
joints and cervical spine. Her range of motion in her lumbar
spine, though, was limited to approximately seventy-five
percent with pain. Hornbaker walked with a stooped gait, but
she could walk without an assistive device and could walk on
her heels and toes. Brownfield diagnosed, inter
alia, moderate low back pain with degenerative disc
disease and moderate COPD. He opined that she had moderate to
severe limitations in lifting, stooping, and maintaining
prolonged positions, and moderate to severe limitations in
exertion.
On
November 5, 2016, Hornbaker sought emergency room care at the
Fulton County Hospital for complaints of pain in her head,
neck, and shoulders. See Transcript at 735-753.
Testing was performed, and the following diagnosis was made:
“[m]ultilevel moderate to severe cervical degenerative
change predominately involving C5-C6 and C6-C7 with neural
foraminal stenosis as above.” See Transcript
at 745-746.
An MRI
of Hornback's cervical spine was performed on November
29, 2016. The physician who interpreted the results found, in
part, the following: “[m]ultilevel degenerative changes
of the spine ..., most significant at the C4-C5, C5-C6, and
C6-C7 levels with areas of moderate to severe spinal canal
stenosis with some associated flattening and compression of
the cervical spinal cord, ” and “[a]dditional
areas of neural foraminal stenosis ...” See
Transcript at 808.
Hornbaker
was thereafter seen by Dr. Steven Cathey, MD,
(“Cathey”) for a neurosurgical consultation.
Cathey examined Hornback and offered the following assessment
in a letter dated December 6, 2016:
... As you recall, [Hornbaker] is filing for long-term
disability benefits through Social Security for chronic
mechanical neck pain with associated paresthesia in both
upper extremities. Physical therapy actually exacerbated the
problem. Her pain is poorly controlled by medication,
specifically tramadol.
A recent MRI of her cervical spine reports multilevel
degenerative changes. Unfortunately, [she] did not bring the
films with her so I have not had an opportunity to review
them firsthand.
... I would certainly like to review her MRI scan firsthand
before making additional recommendations. ... Based on
today's exam, I suspect she is disabled with regard to
future gainful employment. ...
See Transcript at 772.
Cathey
thereafter obtained the MRI of Hornbaker's cervical
spine. He reviewed the results and offered the following
assessment in a letter dated December 19, 2016:
... Hornbaker's MRI scan of her cervical spine arrived
today in the office for review. While she does have a degree
of multilevel canal stenosis, there is no significant ...