United States District Court, N.D. Alabama, Eastern Division
DAVID PROCTOR UNITED STATES DISTRICT JUDGE
to 42 U.S.C. § 405(g), Plaintiff Jennifer MacFarlane
seeks judicial review of a final adverse decision of the
Commissioner of Social Security. The Commissioner denied
Plaintiff's claim for a period of disability and
disability insurance benefits (“DIB”). After
careful review, the court finds that the decision of the
Commissioner is due to be reversed and remanded for further
applied for Supplemental Security Income (“SSI”)
benefits on August 19, 2014, alleging a disability onset date
of January 9, 2014. (R. 62, 133). The Commissioner initially
denied Plaintiff's claim on October 24, 2014. (R. 73).
Plaintiff requested a hearing before an Administrative Law
Judge (“ALJ”) on November 10, 2014. (R. 77).
Subsequently, the ALJ issued a decision unfavorable to
Plaintiff dated February 15, 2017. (R. 33). On September 30,
2017, the Appeals Council declined Plaintiff's request
for review (R. 1-6), making the Commissioner's decision
final and properly before this court for review. See
42 U.S.C. § 405(g).
was born on October 4, 1972 and was 41 years old on the date
of alleged disability onset. (R. 133). She speaks English and
completed high school and one year of college. (R. 169, 171).
Plaintiff alleges that migraines, high blood pressure, lumbar
spondylolisthesis, and back pain limit her ability to work.
(R. 63, 170).
fifteen years preceding Plaintiff's alleged onset
disability date, Plaintiff worked as a waitress, cook, sales
associate, and store cashier. (R. 54, 156-58). In 2013,
Plaintiff was let go from Family Dollar and did not return to
the work force. (R. 54, 170).
being involved in a motor vehicle accident, Plaintiff began
treatment with Dr. James Beretta at the Beretta Pain Clinic
on March 24, 2014. (R. 247). The accident reportedly
exacerbated her previously-existing spondylolisthesis, most
notably her neck and back pain. (R. 247, 258). Dr. Beretta
found decreased rotation in the cervical spine, tenderness in
the paraspinal musculature, increased kyphosis in the
thoracic spine, and a tender lumbar spine. (R. 247). Dr.
Beretta diagnosed Plaintiff with cervical herniated disc,
cervical radiculopathy, and aggravated lumbar spondylosis.
(R. 247-48). He prescribed Ultram and Robaxin and planned for
bilateral L5-S1 transforaminal epidural steroid injection.
(Id.). Plaintiff received the epidural steroid
injection on April 15, 2014. (R. 247, 249).
19, 2014, Plaintiff sought treatment from neurologist Dr.
James White. (R. 253, 495-96). Plaintiff reported mild to
moderate neck pain and severe “unrelenting” back
pain, making it impossible to participate in any activities.
(R. 495). She reported that the pain was relieved
“somewhat when lying down” and that she had tried
epidural injections received at the Beretta Pain Clinic which
“has not helped.” (Id.). On examination,
Dr. White found that Plaintiff had normal gait and station.
(Id.). Dr. White also found Plaintiff to have 1 and
symmetrical deep tendon reflexes, a positive straight leg
raising test bilaterally at 45 degrees, and no overt sensory
or motor deficits. (Id.). Dr. White's impression
was that Plaintiff was experiencing a minimally symptomatic
herniated disc at C5 and a central herniated disc at LS with
a grade one to two spondylolisthesis. (R. 496). Dr. White
noted that Plaintiff would need surgical intervention in
light of her report that the epidural injection was not
April 8, 2015, almost a year after her visit with Dr. White,
Plaintiff sought treatment with Dr. Brian Scholl at The
Orthopedic Center. (R. 653). At that consult, Plaintiff
reported that she was frustrated with the persistence of neck
and back pain and that she experienced significant weight
gain over the preceding two years as a result.
(Id.). On examination, Plaintiff had range of motion
of chin to chest, 45 degrees of extension, 70 degrees of
rotation, and negative Spurling's and Lhermitte's
tests. (Id.). Dr. Scholl noted that Plaintiff
presented significant back pain in the lumbar spine, but had
a normal gait and intact heel, toe, and tandem walking.
(Id.). Dr. Scholl diagnosed Plaintiff with lumbar
spondylolisthesis at L4-L5. (Id.). Dr. Scholl
discussed treatment options with Plaintiff including a
posterior spinal instrumented fusion and Gill laminectomy at
month later, on May 7, 2015, Plaintiff returned to Dr. Scholl
for an epidural injection. (R. 650). This time she reported
that the last epidural shot “helped out quite a bit,
” but the pain returned after working in a flowerbed.
(Id.). On examination, Dr. Scholl found that
Plaintiff had 5/5 motor range from C5-C8 and L2-S1, and noted
that the epidural would be repeated. (Id.). On July
22, 2015, Plaintiff underwent an epidural injection procedure
at Crestwood Medical Center. (R. 664).
August 6, 2015, Plaintiff returned to Dr. Scholl reporting
that her back pain had improved after the last epidural
injection. (R. 739). On examination, Dr. Scholl reported that
Plaintiff had 5/5 motor strength from C5-C8 and L2-S1 with
normal gait, station, and coordination. (Id.). Dr.
Scholl's treatment notes indicate that the claimant was
considering surgical treatment but would continue
conservative care and attempt to lose weight. (R. 739-41).
November 2015, Plaintiff visited Premier Family Care with
complaints of back pain, including the report of the
sensation of “giv[ing] out” in her leg. (R.
769-72). Dr. Youngblood, the treating physician at Premier
Family Care, noted spinal and paraspinal tenderness on
examination. (R. 771). However, during the examination,
Plaintiff reported that she was able to carry out activities
of daily living. (R. 769).
January 7, 2016, Plaintiff returned to Dr. Scholl again
complaining of pain associated with her back. (R. 758). Dr.
Scholl noted that Plaintiff had failed all attempts of
conservative care and was “quite frustrated” with
the persistence of symptoms. (Id.). On examination,
Dr. Scholl reported that Plaintiff had 5/5 strength from
C5-C8 and L2-S1 with normal gait, station, and coordination.
(R. 759). Dr. Scholl developed a surgical plan with
Plaintiff, proposing a Gill laminectomy with posterior spinal
instrumented fusion at L5-S1. (Id.). Dr. Scholl
required that Plaintiff get an updated MRI before surgical
treatment. (Id.). On January 18, 2016,
Plaintiff's MRI showed “bilateral L5 pars defects
with mild associated grade 1 spondylolisthesis” and
moderate bilateral neural foraminal stenosis. (R. 761).
months later, on March 9, 2016, Plaintiff underwent a Gill
laminectomy of L5-S1 with posterior spinal instrumented
fusion, interbody arthrodesis, and application of a
biomechanical device and instrumentation at ¶ 5-S1. (R.
782-83). She had a “normal uneventful postoperative
course” and was discharged the following day. (R. 783).
However, on March 22, 2016, Plaintiff presented to the
emergency department of Huntsville Hospital complaining of
swelling, back pain, and shortness of breath. (R. 785). On
examination, the emergency room physician found that
Plaintiff had an epidural fluid collection compressing the
cauda equina. (R. 787). Plaintiff underwent evacuation of a