Castano v. Astrue

650 F. Supp. 2d 270, 2009 U.S. Dist. LEXIS 81217
CourtDistrict Court, E.D. New York
DecidedSeptember 4, 2009
Docket08 Civ. 3917(BMC)
StatusPublished
Cited by10 cases

This text of 650 F. Supp. 2d 270 (Castano v. Astrue) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Castano v. Astrue, 650 F. Supp. 2d 270, 2009 U.S. Dist. LEXIS 81217 (E.D.N.Y. 2009).

Opinion

MEMORANDUM DECISION AND ORDER

COGAN, District Judge.

Plaintiff challenges defendant’s denial of his application for Social Security disability benefits. Plaintiff suffers from two impairments: the lasting effects of an injured back, and an affective (mental) disorder. In his motion for judgment on the pleadings, plaintiff argues that the Administrative Law Judge ignored critical medical evidence; improperly rejected treating physician reports; and failed to consider the functional limitations imposed on plaintiff by his affective disorder.

I hold that plaintiff is correct as to the first two of his asserted points and therefore I need not reach the third. When the record is viewed as a whole, there is no substantial evidence to support the ALJ’s conclusion, and the overwhelming weight of the evidence compels a conclusion of disability. As the record is complete and defendant has not shown good cause for a remand for further hearings as to disability, plaintiffs motion is granted, and the case is remanded solely for the calculation of benefits.

BACKGROUND

At the time of the hearing before the ALJ on June 25, 2007, plaintiff was 27 years old, with a B.S. degree from the College of Aeronautics. He had been severely injured two years before, on March 23, 2005, when, while working as a helicopter repair mechanic for a private contractor at Fort Drum, a helicopter door swung open. Plaintiff was working on the floor cleaning hydraulic fluid; the door struck him in the back, fracturing his L5 vertebra. After the injury and during the course of his treatment over the next 34 months, plaintiffs subjective complaints of pain in his back were consistently communicated to all of the doctors who examined him. At various times, he used a cane for ambulation. The reports indicate for the most part that as time went on after his injury, the pain got worse.

All of plaintiffs back problems, and very possibly his mental problems, stem from this accident. Although plaintiff attempted chiropractic treatment for two years, the record indicates that his doctors were considering surgical intervention from the first time that he saw an M.D. He ultimately had major surgery, inserting pedicle screws into his spine and fusing his vertebra, in January 2008, a fact that the ALJ appears not to have considered. A summary of the medical findings leading up to that surgery is set forth below.

A. Plaintiffs Treating Physicians 1

1. Dr. Bonnie Glassman (Chiropractor)

After receiving unsatisfactory treatment for his fractured vertebra locally, plaintiff *272 was treated in New York City starting about three months after the accident, first by seeing a chiropractor, Dr. Bonnie Glassman. By that time (June 15, 2005), his weight had increased from 160 to 190 lbs. Dr. Glassman found that he moved with great difficulty. The range of motion in his lower back was half of the normal range. She diagnosed a number of lumbar and sacral conditions, and put him on an eight week course of intensive physical therapy. Her diagnosis was supported not only by her examination, but by x-rays. She extended his treatment program and saw him at least once more, in August 2005.

Throughout her treatment of plaintiff, Dr. Glassman, based on her examinations, the x-rays, and plaintiffs reporting, expressed the view that plaintiff had severe limitations on his ability to sit, stand or lift. In the June and August examinations, she found his ability to sit or stand limited to 30 minutes. In September 2005, she filled out a Physical Assessment Report for the New York State Office of Temporary and Disability Assistance. In that report, she found a little improvement, that he could sit or stand for two hours, and stated that she expected this condition to last 6-8 months.

2. Seaport Orthopedic Associates

Plaintiff received treatment from two doctors in this medical group, Dr. Jeffrey Goldstein and Dr. Douglas C. Schottenstein, both of whom are board certified orthopedic surgeons, starting in December 2005. After reviewing x-ray and MRI films, Dr. Goldstein found spina bifida occulta and a disc bulge at L4-5. Spina bifida occulta refers to a small opening in the vertebra that would normally be closed to protect the nerves from exposure that could result in pain. Dr. Goldstein also ordered a CT scan, as he was concerned about the possibility of spondylolysis. Spondylolysis is a defect sometimes resulting from a healed fracture to a part of a vertebra, usually the L5 vertebra, called the pars interarticularis, which can result in pain of varying intensity. The following two illustrations show, first, the position of the pars interarticularis and, second, the presence of spondylolysis:

*273 [[Image here]]

After reviewing the CT Scan, Dr. Schottenstein concluded that in fact plaintiff had spondylolysis. The pars was also enlarged (hypertrophic) and hardened (sclerotic), which could also cause or contribute to pain. The CAT scan also confirmed the spina bifida occulta. To put it in layperson’s terms, the MRI was consistent with injuries resulting from an impact to his lower spine which had in part healed, but which had left lasting manifestations.

Dr. Schottenstein completed a functional assessment form prior to the hearing of this matter, although the precise date of his assessment is not clear except that it occurred after April 2006. He concluded, with reference to the MRI and CT scan, that plaintiff could stand and/or walk less than two hours per eight hour work day; sit less than four hours; and could lift and/or carry less than 10 pounds.

After the hearing, but about a month before release of the ALJ’s decision, Dr. Goldstein surgically repaired the L5 fracture by inserting pedicle screws in it and fusing the pars interartcularis. He also cut away the arches on the L5 disc, grafting the bone so that it would hold the pedicle screws. The ALJ was provided with these records several days prior to the issuance of his decision.

In the months leading up to the surgery, Dr. Goldstein had repeatedly advised plaintiff of the pros and cons of the procedure. He communicated to plaintiff that even with the pars repair that he ultimately performed, plaintiff might still suffer from significant pain: “The patient understands that I believe he is at significant risk for continued symptomatology even following surgery for his spondylolysis at L5.” Plaintiff nevertheless elected to have the surgery.

3. Downtown Physical and Rehabilitation Miedicine, P.C. (physiatry)

Dr. Goldberg referred plaintiff to this medical group (“DPRM”), where he was treated by two physicians, Dr. Michael J. Neely and Dr. Andrew Brown. Both of these doctors are board certified physiatrists. Their review of the CT scan also confirmed spondylolysis. They considered, and for the most part prescribed, a broad range of escalating treatments, ranging from over-the-counter analgesics, to pain medication patches, to spinal injec *274 tions (administered by Dr. Schottenstein), 2 and ultimately the surgery which plaintiff received from Seaport Orthopedic.

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Bluebook (online)
650 F. Supp. 2d 270, 2009 U.S. Dist. LEXIS 81217, Counsel Stack Legal Research, https://law.counselstack.com/opinion/castano-v-astrue-nyed-2009.