Gordon v. HHS

District Court, D. New Hampshire·Decided March 31, 1994·No. CV-93-132-B·Published

Opinion

Gordon v . HHS CV-93-132-B 03/31/94 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Albert E . Gordon

v. Civil N o . 93-132-B Secretary of Health and Human Services

O R D E R

Albert Gordon brings this action pursuant to 42 U.S.C.A. § 405(g) (West Supp. 1993), challenging a final determination by the Secretary of Health and Human Services ("Secretary") denying his application for Social Security disability benefits. Presently before the court are Plaintiff's Motion for Order

Reversing the Decision of the Secretary, and Defendant's Motion to Affirm the Secretary's Decision.

I. STANDARD OF REVIEW

Pursuant to 42 U.S.C.A. § 405(g), the court is empowered to "enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Secretary, with or without remanding the cause for a rehearing." In reviewing a Social Security decision, the factual findings of the Secretary "shall be conclusive if supported by 'substantial

evidence.'" Irlanda Ortiz v . Secretary of Health & Human Serv., 955 F.2d 765, 769 (1st Cir. 1991) (quoting 42 U.S.C. § 405(g)). 1

Thus the court must "'uphold the Secretary's findings . . . if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [the Secretary's] conclusion.'" Id. (quoting Rodriguez v . Secretary of Health & Human Serv., 647 F.2d 2 1 8 , 222 (1st Cir. 1981)). Moreover, it is the Secretary's responsibility to "determine issues of credibility and to draw inferences from the record evidence," and "the resolution of conflicts in the evidence is for the Secretary, not the courts." Irlanda Ortiz, 955 F.2d at 769 (citing Rodriguez, 647 F.2d at 2 2 2 ) .

II. BACKGROUND

Gordon was born on June 2 3 , 1942. He has a ninth grade

education and has received his Graduate Equivalency Degree while he was in the military. His job history includes positions in an

1 The Supreme Court has defined 'substantial evidence' as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v . Perales, 91 S . C t . 1420, 1427 (1971). "This is something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency's finding from being supported by substantial evidence." Consolo v . Federal Maritime Comm'n, 86 S . C t . 1018, 1026 (1966).

automobile body shop, performing jobs such as straightening, painting, and body work, however, he is not a qualified automobile mechanic. Gordon asks this court to review the findings and determinations of the Secretary, and either remand for further hearing or rule that he is entitled to benefits from January 8 , 1991 to date.

A. Medical History Gordon's medical records indicate that in 1981 he underwent back surgery to treat decompression of a nerve root. Although he recovered completely from this initial surgery, his pain recurred in January 1990 when he was bending over to pick up a garage door. He sought medical treatment from D r . Hoke Shirley in December 1990 when he again suffered pain while using a sledge hammer at work. His symptoms included lower back pain and

associated numbness on the plantar surface of his foot, but he experienced no weakness in his lower extremities. D r . Shirley's

diagnosis was left lumbar radicular syndrome, most likely caused by a prolapsed disk in the L4 - L5 region. Gordon was referred to physical therapy.

In January 1991, D r . Shirley expressed the view that Gordon needed to discontinue work and start a physical therapy program, which Gordon complied with. In February, D r . Shirley noted that

Gordon's condition had improved only minimally, with tenderness bilaterally in the iliolumbar angles and over the spinuous processes of L3 through L 5 . D r . Shirley scheduled an MRI which showed no herniated discs, though it did reveal some scarring and fibrosis at the level L5-S1 without clear radicular encroachment. He referred Gordon to D r . David J. Nagel to perform EMG/NCV studies.

Gordon saw D r . Nagel in April 1991, for electrophysiologic studies. After performing the necessary tests, D r . Nagel concluded that the results were consistent with a diagnosis of a left S1 radiculopathy.

Gordon saw D r . Shirley again in April 1991, where he noted that Gordon's condition was continuing to decline. Gordon was exhibiting pain down the back of his right leg which inhibited

his ability to continue with physical therapy. D r . Shirley prescribed a steroid injection through D r . Beasley and a

continued physical therapy program.

Gordon was referred to D r . Scala and D r . Sachs in May 1991, who performed various physical tests. Gordon had a symmetric gait, and was able to toe and heel walk without problem, but was only able to bring his finger tips to the level of his knees bending forward. Gordon had normal range of motion for shoulder

twisting, trunk twisting, and side bending, and showed good range of motion of all joints in both lower extremities. D r . Sachs diagnosed Gordon as having: 1 ) a failed previous lumbar spine laminectomy discectomy syndrome with persistent pain, 2 ) a prolapsed lumbar disc which could be a discogenic lumbar radicular pain syndrome, 3 ) some remnants of internal disc derangement and disruption particularly at L5-S1 which would correspond to his previous surgery, 4 ) a weight problem. He recommended further evaluation through a lumbar discography to find out which disc was causing the problem, and further physical therapy and nutritional consultation. He also prescribed Feldene, a non-steroid anti-inflammatory drug.

The results of Gordon's discogram were very nonspecific and did not reveal the pathologic source of Gordon's pain. D r . Sachs

noted that Gordon was "wavering and facilitating" in his responses and could not say what was causing his pain. He noted

some abnormal discs but did not feel that there was a specific area that could be addressed with surgical intervention or further testing. He reiterated the previous 4-part diagnosis and discharged Gordon from his care stating that he could offer no further treatment or diagnoses.

Gordon returned to D r . Nagel in August 1991, complaining of

stabbing, aching pain across the back that extended down both legs as far as the knee. This pain also resulted in tingling in Gordon's left foot. Gordon asserted that the pain was exacerbated by lifting or prolonged walking, and that it kept him awake at night. D r . Nagel opined that Gordon had multilevel disc disease at L2-3, L3-4, L4-5 and L5-S1, which was consistent with an S1 radiculopathy. He recommended that Gordon begin swim therapy to improve his conditioning and flexibility and that he get vocational counseling. He also recommended a diagnostic nerve block of the L5-S1 nerve root to determine Gordon's pain generator.

Gordon's condition continued with the same symptoms through September 1991. At that time D r . Nagel noted that Gordon had been diagnosed as being able to return to work by D r . Sachs, with

limitations of 6 hours per day at a sedentary to light level job, not lifting more than 20 pounds, not sitting for more than 30

minutes, and not carrying more than 20 pounds. He opined that if Gordon did not respond to cortisone injections these restrictions would be a permanent limitation.

Gordon reported increasing pain in November 1991, after a doctor forcibly twisted him while he was in a flexed position. Dr. Nagel increased Gordon's pain medication and recommended

setting up an appointment with D r . Beasley, which Gordon did. In December, 1991 Gordon continued to experience residual increased pain from the procedure in November, but was seeking help from Dr. Beasley and taking Tylenol # 4 , twice daily. D r . Nagel opined that Gordon as capable of sedentary work at best at about 4 hours a day at that time.

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