Roach v. Saul

CourtDistrict Court, N.D. California
DecidedJuly 17, 2020
Docket3:19-cv-03921-TSH
StatusUnknown

This text of Roach v. Saul (Roach v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Roach v. Saul, (N.D. Cal. 2020).

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 CHRISTOPHER R.,1 Case No. 19-cv-03921-TSH

8 Plaintiff, ORDER RE: CROSS-MOTIONS FOR 9 v. SUMMARY JUDGMENT

10 ANDREW SAUL, Re: Dkt. Nos. 18, 24 11 Defendant.

12 13 I. INTRODUCTION 14 Plaintiff Christopher R. brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial 15 review of a final decision of Defendant Andrew Saul, Commissioner of Social Security, denying 16 Plaintiff’s claim for disability benefits. Pending before the Court are the parties’ cross-motions for 17 summary judgment. ECF Nos. 18 (Pl.’s Mot.), 24 (Def.’s Mot.). Pursuant to Civil Local Rule 16- 18 5, the motions have been submitted without oral argument. Having reviewed the parties’ 19 positions, the Administrative Record (“AR”), and relevant legal authority, the Court hereby 20 GRANTS Plaintiff’s motion, DENIES Defendant’s cross-motion, and REMANDS for further 21 proceedings consistent with this Order. 22 II. BACKGROUND 23 A. Age, Education and Work Experience 24 Plaintiff is 38 years old years old. AR 144. He has prior work experience as a 25 microcomputer support specialist, electrician, and furniture mover. AR 47. 26

27 1 Partially redacted in compliance with Federal Rule of Civil Procedure 5.2(c)(2)(B) and the 1 B. Medical Evidence 2 In 2011, Plaintiff was laying electrical cable as a contractor in Afghanistan when he 3 injured his back. AR 268. Notes from the Sharana Aid Station Clinic in Afghanistan from 4 September 2011 reported that he had upper back pain that had lasted for over a week. Id. Plaintiff 5 attempted physical therapy without improvement and was flown to a hospital. AR 268, 275. He 6 was treated with a cervical manipulation that worsened his pain. Id. (both). Plaintiff stated that 7 his pain was unrelenting and worsened with moving, lifting, bending, and raising his arms. AR 8 268. His pain was interfering with sleep and his work duties. Id. 9 On examination, he had pain with extension, flexion, rotation, or twisting of his neck, 10 reduced range of motion of up to a 50% decrease in flexion and side bending, and positive straight 11 leg raise tests. AR 269. He also complained of lower back pain. Id. The evaluation revealed 12 neck sprain/strain but no neurological deficits. Id. At that time, no physical therapy or other 13 treatment was recommended, and he was instead advised to take anti-inflammatory medication 14 such as Motrin or Advil and to rest off-duty for ten days, then resume light duty work assuming 15 the absence of any additional findings. Id. 16 By September 30, 2011, Plaintiff had returned to California and was provided with a 17 referral to a spine clinic after presenting to an emergency room for neck pain. AR 308-09. On 18 October 11, 2011, Chiropractor Brandon L. Roberts, D.C. advised him to remain off work until 19 October 31 to avoid aggravating his condition. AR 287. 20 A cervical spine MRI from October 26, 2011 showed straightening of the cervical spine 21 with muscle spasm and/or strain and there was a left paracentral C6-7 disc protrusion effacing the 22 left spinal cord, though without impingement. AR 295. 23 On October 28, 2011, Paul Nottingham, M.D., performed an initial evaluation, during 24 which Plaintiff advised him that his pain had improved and he hoped to return to work. AR 321. 25 During the course of his treatment, Dr. Nottingham instructed Plaintiff to remain off work for 26 several periods of time from at least November 22, 2011 through March 1, 2014. AR 371, 431, 27 443, 481, 484, 511, 529, 590-91. 1 reported “good relief” from chiropractic treatment, feeling “much better” despite residual neck 2 stiffness, and that he hoped to return to his usual work. AR 321. He also reported being able to 3 drive, turn his head at 90 degrees and perform activities of daily living without difficulty and pain. 4 Id. On examination, he was largely normal and had “full cervical flexion and extension without 5 pain upon overpressure.” Id. During a physical therapy evaluation on November 10, 2011, 6 Plaintiff’s ranges of motion were “full” and his strength was 4-5/5 with no or only “mild” pain. 7 AR 316. 8 In January 2012 Plaintiff underwent a nerve conduction study that found mild to moderate 9 median nerve compromise from the wrist through the carpal tunnel on the left and mild median 10 nerve compromise on the right. AR 545. He presented “with no acute evidence of axonal 11 disruption.” Id. 12 On February 27, 2012, Kasra Amirdelfan, M.D. reviewed the October 26, 2011, MRI C- 13 Spine and diagnosed Plaintiff with brachial neuritis. AR 298-99. Dr. Amirdelfan recommended a 14 surgical referral if the pain was not well controlled with medication and injections. AR 298. On 15 March 13, 2012, Dr. Amirdelfan treated Plaintiff with a cervical epidural steroid injection for his 16 cervical radiculopathy. AR 295-97. 17 In April and May 2012 Plaintiff continued physical therapy. AR 333-36. However, he 18 missed several sessions because of illness, transportation difficulties, and a misunderstanding 19 about whether he was to continue therapy, including that he was allegedly told he did not need to 20 finish treatment. AR 333-36, 342. 21 Notes from an August 24, 2012 MRI indicate that the findings were not significantly 22 changed. AR 435-36. In particular, neural foramina were patent at C6-7, and there was “limited” 23 narrowing and “no stenosis” at other levels. Id. 24 On September 12, 2012, Dr. Nottingham recommended surgical intervention. AR 491. 25 One month later, Plaintiff underwent neck surgery, with a fusion at C6-7. AR 461. The surgery 26 was apparently complicated by delayed fusion and pseudo-arthritis, but Plaintiff ultimately 27 responded to additional time and bone stimulator treatment. AR 347. 1 of the cervical spine lordosis which may be secondary to muscle spasm,” but described all other 2 findings as stable (mild bulge and annular fissure, mild central stenosis without foraminal 3 narrowing, and no bone edema or ligamentous injury). AR 385-86. 4 On October 29, 2012, Plaintiff underwent an anterior C6-C7 discectomy with plate and 5 screw fixation and a bone graft to repair left arm radiculopathy “without any difficulty.” AR 461- 6 64. 7 A diagnostic study of Plaintiff’s neck in March 2013 revealed no stenosis. AR 423. 8 On September 14, 2013, Plaintiff went to the emergency room for leg pain. AR 304. 9 Patrice Ringo, M.D. diagnosed left leg pain but noted no abnormal findings and sent Plaintiff 10 home. AR 305-06. 11 On September 25, 2013, Plaintiff saw Adolfo Romero-Duran, M.D. for severe left ankle 12 pain, after injuring it in the parking lot of his apartment. AR 759-60. Dr. Romero-Duran noted 13 that Plaintiff had chronic low back pain and cervical neuropathy. AR 760. 14 Plaintiff continued physical therapy in October 2013 for a left ankle sprain as well as 15 cervical and scapular pain radiating through his left arm with numbness and tingling. AR 326. He 16 reported only temporary relief after therapy and needing to take Norco during the day and 17 Baclofen at night. Id. On examination the therapist found Plaintiff had reduced range of motion 18 in his cervical spine (extension, rotation, and pain with lateral flexion). Id. 19 In November 2013 Kevin C. Booth, M.D. completed an Independent Medical Evaluation 20 in connection with Plaintiff’s worker’s compensation claim. AR 736-38. He opined that Plaintiff 21 was not malingering and that he “is unable to return to work at this time without restrictions.

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Roach v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/roach-v-saul-cand-2020.