Gaylor v. Astrue

292 F. App'x 506
CourtCourt of Appeals for the Seventh Circuit
DecidedSeptember 8, 2008
DocketNo. 07-2206
StatusPublished
Cited by5 cases

This text of 292 F. App'x 506 (Gaylor v. Astrue) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Gaylor v. Astrue, 292 F. App'x 506 (7th Cir. 2008).

Opinion

ORDER

Shawn Gaylor injured his back in 1996 and has since undergone four surgical procedures and has been treated for depression and anxiety. He stopped working in January 2001, claiming that he was in too much pain to continue. Numerous doctors have treated Gaylor and have reviewed his medical records. Some of them conclude that he is unable to work, while others say that he can perform limited work. In denying Gaylor’s claim for Social Security disability benefits, the ALJ found that Gaylor’s back injury was not severe enough to qualify for coverage and that Gaylor’s account of his pain was exaggerated and not credible. The ALJ also found that Gaylor’s mental impairments were severe but did not foreclose all avenues of employment. The Appeals Council affirmed, and the district court upheld the decision of the ALJ. Because the ALJ’s credibility determination and functional capacity determination were not supported by substantial evidence, however, we reverse and remand.

I. BACKGROUND

A. Gaylor’s claim of disability based on his back injuries

Gaylor, currently age 38, first experienced back problems in 1996 when he felt a sharp “pop” in his lower back while working for Chrysler. Orthopedic surgeon Dr. Michael Coscia has been treating Gay-lor since 1998. Early on Dr. Coscia diagnosed dehydration and degeneration in Gaylor’s spine as well as herniation and an annular tear. He noted that by 1999 Gay-lor had already undergone two epidural steroid injections with no pain relief. Dr. Coscia referred Gaylor to Dr. John McLi-more to manage Gaylor’s pain. Dr. McLi-more prescribed some pain medications when surgical procedures failed to relieve Gaylor’s symptoms, but he also attempted to wean Gaylor off of the medication, noting that he was at risk of dependency.

Gaylor also saw Dr. Chakropani Gupta in 1999 for a lumbar discogram, which confirmed that Gaylor had significant disk degeneration with a total disruption of the nucleus and “multiple, concentric annular tears, and [an] anterior and a posterior annular tear” causing severe lower back pain and right buttock and leg pain. In late 1999, Dr. Gupta also performed an invasive procedure called intradiscal elec-trothermal therapy, which resulted in about a 50% improvement in Gaylor’s pain. But this relief lasted only for about three months, when his pain became significantly worse. This concluded Dr. Gupta’s treatment of Gaylor.

In early 2000, Dr. Coscia performed several surgical procedures on Gaylor “[d]ue to positive MRI scan findings and [a] failure of extensive nonoperative surgical therapy.” Specifically, Dr. Coscia performed a hemilaminotomy, foramintomy, diskectomy, and a canal and nerve root decompression procedure. But after a month, Gaylor noted continued pain, and in mid-2001 Gaylor was again reporting severe pain. Dr. Coscia attempted dietary supplements to restore Gaylor’s damaged cartilage but noted that the final alternative would be a spinal fusion. Also in 2001 Gaylor’s family physician at the time, Dr. Phillip Whitfield, confirmed the danger of pain medication addiction identified by Dr. McLimore but noted that no other options were available to help Gaylor cope. Gay-lor testified that he cooperated with the doctors’ attempt to wean him from pain medication, but that the attempt was un[509]*509successful because the resultant pain was too severe and he was totally incapacitated.

By the end of 2002, a “persistent severe” pain prompted Dr. Coscia to perform a spinal fusion at two levels in Gaylor’s back. Afterward, Gaylor experienced about two weeks of relief but then returned to taking large quantities of pain medication and reporting that his degree of pain was unchanged. Despite these reports, Dr. Cos-cia noted that the fusion had been a success and that there was no sign of any complications. He concluded that Gaylor was deconditioned to pain and needed to be weaned from his medication.

Through 2003, Gaylor was still reporting “dramatic disabling” pain to Dr. Coscia, but Dr. Coscia concluded that Gaylor did not suffer from a long-term disability. In early 2003 Dr. McLimore opined that Gay-lor seemed more comfortable than the degree of pain he claimed to experience.

Dr. Eric Heathers, who had treated Gaylor as his family physician in 1999 and 2000 before Dr. Whitfield, began seeing him again in 2003. Dr. Heathers confirmed Gaylor’s injuries and that he experienced a limited range of motion, limited reflexes, and limited strength. By late 2003, Dr. Heathers reported that he had seen Gaylor thirty-six times since 1998 and that his symptoms had not improved despite surgery. Moreover, he found that Gaylor’s pain was consistent with the injuries identified in his back. He determined that Gaylor experienced persistent pain, spasms, loss of motion, loss of strength, and loss of sensation, and that Gaylor’s condition required him to change position more than once every two hours. Contrary to Dr. Coscia, Dr. Heathers determined that Gaylor’s symptoms would interfere with his ability to maintain reliable attendance at work and that, at best, he could work three days a week with some limitations.

Gaylor also saw Dr. Lynette Green-Mack, who specializes in spine rehabilitation, beginning in 2003. She diagnosed him with chronic pain secondary to failed back, post lumbar laminectomy syndrome, lumbar facet syndrome or lumbosacral spondylosis, and sacroiliitis, and she prescribed medication for persistent pain. As surgery and six epidurals had failed to decrease Gaylor’s pain, she attempted nerve block and joint block procedures as a possible solution and continued to attempt pain patches and additional medication as well. She found that Gaylor’s symptoms were consistent with the medical evidence and that he would be prevented from maintaining reliable attendance at work. She also noted Gaylor’s need to change position more than once every two hours.

Also in 2003, Dr. Coscia referred Gaylor to Dr. Terry Trammel for a second opinion on his continued back pain after fusion surgery. Gaylor reported constant, easily aggravated pain, with his leg pain exceeding his back pain, and that no treatment had given him lasting relief. Dr. Trammel diagnosed post-fusion syndrome, but found that Gaylor’s fusion was “solid” and opined that Gaylor was doing well and had reached maximum medical improvement. He determined that Gaylor was not markedly disabled from his pain. In his own records, however, Dr. Trammel noted that he told Gaylor that even a successful fusion operation had less than a 50% chance of alleviating his pain for a prolonged period.

Throughout, Gaylor was also referred to other physicians for additional pain management. He also briefly attended physical therapy that caused an increase in his pain, and he testified that he discontinued [510]*510treatment because the pain became intolerable.

In summary, Drs. Coscia and Trammel opined that Gaylor could work with limitations, but Drs. Heathers and Green-Mack opined that he could not work. Dr. McLi-more did not make a conclusion one way or the other but was concerned about Gay-lor’s possible addiction to pain medication and questioned the severity of Gaylor’s pain.

Gaylor testified that he needs to lie down most of the day and that he experiences uncontrollable pain once or twice a week that leaves him in bed from several hours a day to days at a time. He has a constant pain level of about 7 to 8 on a scale of 10 and cares for his children only when they require little more than simple meal preparation and supervision.

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Bluebook (online)
292 F. App'x 506, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gaylor-v-astrue-ca7-2008.