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Kolb v. Berryhill

United States District Court, D. South Carolina

January 23, 2018

Lisa Jane Velluto Kolb, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.



         This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for Disability Insurance Benefits (“DIB”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On June 12, 2014, Plaintiff protectively filed an application for DIB[1] in which she alleged her disability began on May 21, 2012. Tr. at 70 and 170-73. Her application was denied initially and upon reconsideration. Tr. at 103-06 and 112-17. On March 22, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) John T. Molleur. Tr. at 35-69 (Hr'g Tr.). The ALJ issued an unfavorable decision on May 4, 2016, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 18-34. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-5. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 27, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 52 years old at the time of the hearing. Tr. at 42. She completed high school and some college, but did not obtain a degree. Id. Her past relevant work (“PRW”) was as an administrative assistant. Tr. at 62. She alleges she has been unable to work since May 21, 2012. Tr. at 170.

         2. Medical History[2]

         Plaintiff initiated treatment with rheumatologist Clarence W. Legerton, M.D. (“Dr. Legerton”), on June 1, 2011. Tr. at 351. She reported that she had been diagnosed with fibromyalgia in 1991 and that her pain had worsened over the prior three- to four-month period, resulting in poor sleep, low energy, weight gain, and depressed mood. Id. Dr. Legerton observed Plaintiff to be morbidly obese. Tr. at 352. He noted the presence of 18 of 18 fibromyalgia tender points. Id. He referred Plaintiff for lab work, prescribed Trazodone and Neurontin, continued Cymbalta, and instructed Plaintiff to walk for exercise. Tr. at 353 and 355.

         Plaintiff presented to Industrial Medical Center on August 8, 2011, after sustaining a three-foot fall from a chair onto the floor and injuring her lower back and tailbone. Tr. at 329. Marcus Schaefer, M.D. (“Dr. Schaefer”), assessed strains to Plaintiff's lumbosacral and thoracic spine. Id. He referred Plaintiff to physical therapy and prescribed ibuprofen and Skelaxin. Id.

         Plaintiff presented to the emergency room (“ER”) at Moncks Corner Medical Center the next day with complaints of a headache and severe neck pain. Tr. at 333. Susan M. Smith, M.D. (“Dr. Smith”), described Plaintiff as “in severe distress” and noted decreased range of motion (“ROM”) of the neck; moderate soft tissue tenderness throughout the neck; limited ROM of the back; and moderate tenderness throughout the lumbar spine. Tr. at 333-34. X-rays of Plaintiff's lumbosacral spine showed mild degenerative disc disease at ¶ 4-5 and L5-S1, but x-rays of her cervical spine were normal. Tr. at 334. Dr. Smith assessed lumbar strain and contusion, acute cervical strain, hypertension, and contusion to the coccyx. Id. She prescribed Zofran, Percocet, and Phenergan and instructed Plaintiff to follow up with her doctor in three days if she failed to improve. Tr. at 335-36.

         Plaintiff presented to Doctors Care on August 11, 2011, and reported pain in her sacrum and paraspinous muscles. Tr. at 366. The attending physician assessed a tailbone contusion and a lumbar strain and administered a Toradol injection. Id.

         Plaintiff returned to Doctors Care on August 15, 2011, for neck pain. Tr. at 370. She reported lightheadedness that occurred when she turned to the right and indicated she was afraid to drive. Id. An x-ray of Plaintiff's cervical spine was negative. Id. She had 5/5 neck strength and full ROM. Id. The provider instructed Plaintiff to continue taking Naproxen and Skelaxin and to take Flexeril only at night. Id.

         Plaintiff presented to Sandra Brehmer, FNP (“Ms. Brehmer”), on August 16, 2011, with complaints of back and neck pain. Tr. at 425. She described pain in her tailbone that radiated to her low back and was exacerbated by sitting. Id. She indicated she would experience a “flash” of pain in her neck if she turned it too quickly. Id. Ms. Brehmer observed Plaintiff to appear agitated and in pain. Tr. at 426. She noted restricted ROM in Plaintiff's lumbar and cervical spine. Id.

         Plaintiff underwent magnetic resonance imaging (“MRI”) of her cervical and lumbar spine the same day. Tr. at 402-05. The MRI of her cervical spine showed no severe stenosis, but “scattered mild interspinous ligament edema in the upper and lower cervical spine, possibly due to ligamentous strain or sprain” and mild mid-cervical spondylosis that was most-evident at ¶ 5-6, “where there might be slight contact exiting C6s by foraminal disc osteophyte complexes.” Tr. at 402. The MRI of her lumbar spine indicated mild degenerative disc disease and mild-to-moderate facet arthropathy that was most pronounced at ¶ 3-4 through L5-S1, but no significant stenosis, definite neural contact, or acute fracture. Tr. at 404.

         Plaintiff returned to Dr. Legerton on August 17, 2011, and reported that she had recently sustained a fall that had caused pain in her buttocks, back, and neck. Tr. at 349. She indicated she was having a “bad fibro day, ” but stated it was the first one in three weeks. Id. She reported she was no longer taking Cymbalta, but that her mood was better and her affect was “not as flat.” Id. Dr. Legerton observed Plaintiff to be very tender in her spine and back and diffusely tender in the fibromyalgia tender points. Id. He noted that Plaintiff was “actually doing well” and continued her on her same medications. Id.

         Plaintiff initiated physical therapy for her lumbar spine on August 18, 2011. Tr. at 518. She reported a high level of pain and was unwilling to perform multiple exercises. Tr. at 519. The physical therapist recommended that Plaintiff be seen twice a week for four weeks. Tr. at 520. Plaintiff received subsequent authorization for additional visits. Tr. at 526-27.

         Plaintiff followed up at Doctors Care on August 25, 2011. Tr. at 374. She complained of low back pain that woke her during the night, but indicated her tailbone was no longer hurting. Id. The provider noted that Plaintiff was moving slowly and was unwilling to sit. Id. He prescribed ibuprofen, Skelaxin, and Trazodone and instructed Plaintiff to continue physical therapy and follow up with a neurosurgeon. Id.

         Plaintiff presented to neurosurgeon Joseph M. Marzluff, M.D. (“Dr. Marzluff”), for evaluation of neck and back pain on August 31, 2011. Tr. at 341-42. She reported a history of fibromyalgia, but indicated the new-onset pain was different. Tr. at 341. She described her back pain as primarily axial and endorsed pain in the back of her neck that occasionally radiated into her head and right arm. Id. Dr. Marzluff observed Plaintiff to have restricted ROM of the neck and back in all directions. Id. He indicated that straight-leg raising (“SLR”) at 90 degrees reproduced Plaintiff's back pain, but did not cause radicular pain. Id. He observed no motor, sensory, or reflex abnormality. Id. He stated Plaintiff's symptoms were consistent with cervical and lumbar strain with exacerbation of preexisting degenerative disc disease. Id. Dr. Marzluff indicated Plaintiff did not require surgical intervention. Tr. at 342. He referred her to a pain management physician. Id.

         Plaintiff presented to Summar Phillips, M.D. (“Dr. Phillips”), for an initial pain management evaluation on September 8, 2011. Tr. at 392. She described her neck pain as radiating into the base of her skull and her back pain as radiating across her back and into her left hip, buttock, thigh, and knee. Id. She indicated her pain was exacerbated by turning her head, driving, reading, performing household chores, and typing. Id. Dr. Phillips noted the following abnormalities on examination: tenderness, paraspinous spasm, pain with ROM, and limited flexion, extension, bilateral rotation of the neck; antalgic gait; decreased sensation to the right lower extremity; pain with ROM and paraspinous tenderness in the lumbar spine and sacroiliac (“SI”) joint; painful SLR test on the right; inability to heel and toe walk; bilateral trochanteric bursa tenderness; and pain with ROM of the right hip. Tr. at 394. She assessed cervicalgia, muscle spasm, back pain, radicular syndrome of the lower limbs, radicular syndrome of the upper limbs, spinal stenosis of the lumbar region, degenerative disc disease of the lumbosacral spine, degenerative disc disease of the cervical spine, and facet arthropathy. Id. She discontinued ibuprofen and Flexeril, prescribed Valium and Mobic, and instructed Plaintiff to continue physical therapy. Id. She indicated she would schedule Plaintiff for a cervical epidural steroid injection (“ESI”). Id.

         On September 11, 2011, Plaintiff complained of paresthesias in her left leg, radicular pain in her right leg, bilateral trapezius pain, and headache. Tr. at 379. She indicated that a transcutaneous nerve stimulation (“TENS”) unit had worsened her pain and that physical therapy was providing no relief. Id. The provider authorized additional physical therapy sessions and prescribed Lortab. Id.

         Dr. Phillips administered a cervical ESI at ¶ 5-6 on September 20, 2011. Tr. at 395-96. On September 24, 2011, Plaintiff reported her cervical ROM had slightly improved. Tr. at 383. She indicated she felt better overall, but continued to have some bad days. Id. The provider indicated Plaintiff should continue to work with restrictions for three hours per day, but anticipated that she would be able to increase her work hours at her next visit. Tr. at 384.

         On October 6, 2011, Plaintiff reported that her symptoms had improved during the prior week, but had subsequently worsened. Tr. at 387. She stated she was unable to tolerate any position for longer than 15 to 20 minutes and could not stand for longer than five minutes at a time. Id. The provider referred Plaintiff for additional physical therapy sessions. Id.

         On October 17, 2011, Plaintiff reported that she had discontinued Valium and Mobic on her own because they had been ineffective and had caused side effects. Tr. at 397. She indicated she had restarted ibuprofen and Flexeril. Id. She stated the cervical ESI had allowed her to perform her normal activities in less pain, but continued to report difficulty reading and performing her job. Tr. at 397 and 398. Dr. Phillips observed Plaintiff to have pain with flexion, extension, and bilateral rotation of the neck, paraspinous spasms, and tenderness to the trapezius muscle, but she indicated Plaintiff's ROM was slightly improved. Tr. at 397. Dr. Phillips referred Plaintiff to physical therapy for her neck and indicated she would schedule a second cervical ESI. Tr. at 398. She administered a second ESI at Plaintiff's C5-6 level on October 25, 2011. Tr. at 399-400.

         Plaintiff presented to orthopedic surgeon James K. Aymond, M.D. (“Dr. Aymond”), for an initial evaluation on November 11, 2011. Tr. at 450. She reported pain in her interscapular area and posterior neck and dysesthesias in her left upper extremity. Id. She endorsed some lower back pain, but indicated it had improved since her injury. Id. Dr. Aymond observed Plaintiff to walk with a normal heel-to-toe gait and to be able to heel and toe walk without difficulty. Tr. at 451. He noted slightly reduced deep tendon reflexes in the biceps, brachioradialis, and triceps tendons and a slightly diminished sensory examination in the C6 dermatome distribution bilaterally. Id. Plaintiff had normal sensation in her lower extremities and no radicular pain with SLR test. Id. Dr. Aymond diagnosed lumbar strain and contusion and cervical hyperflexion injury with cervical disc protrusion and uncovertebral joint hypertrophy at the C5-6 level with symptomatic neck pain and upper extremity dysesthesias. Id. He recommended Plaintiff participate in additional physical therapy for her neck and remain on limited duty at work. Tr. at 451 and 529.

         On January 13, 2012, Dr. Aymond observed Plaintiff to have limited ROM in the cervical and lumbar spine, but normal motor and sensory examinations. Tr. at 452. He ordered additional physical therapy sessions for Plaintiff's low back. Id.

         Plaintiff continued to report pain in her bilateral buttocks, low back, and posterior neck on February 17, 2012. Tr. at 455. Dr. Aymond observed limited ROM of the lumbar and cervical spine and pain in the low back and bilateral buttocks on SLR test, but indicated Plaintiff's neurological exam was normal. Id. He recommended Plaintiff obtain an updated MRI scan. Id.

         Plaintiff underwent a second MRI of the lumbar spine on March 12, 2012. Tr. at 406. It indicated mild-to-moderate facet arthropathy that was greatest at ¶ 5-S1, as well as mild degenerative disc changes without disc herniation or stenosis. Id.

         On April 11, 2012, Dr. Aymond noted that the recent MRI of Plaintiff's lumbar spine showed slight disc desiccation at ¶ 4-5 and L5-S1 with no evidence of disc bulge or herniation. Tr. at 457. He noted that Plaintiff had limited flexion and extension of the lumbar spine and was tender over the midline of the lower lumbar spine and the paraspinous muscles. Id. He indicated SLR testing produced low back pain. Id. He prescribed Lortab, Skelaxin, and Motrin and recommended that Plaintiff undergo two lumbar ESIs. Id. He indicated Plaintiff would be limited to lifting 20 pounds or less and should avoid bending, twisting, and sitting in elevated chairs. Tr. at 458 and 459.

         Plaintiff presented to orthopedic surgeon Donald R. Johnson, II, M.D. (“Dr. Johnson”), for an independent medical evaluation (“IME”) on April 30, 2012. Tr. at 412- 13. She complained of low back pain and neck pain that radiated through her upper shoulders and into her right arm. Tr. at 412. Dr. Johnson indicated a cervical MRI showed multilevel degenerative changes and foraminal disc and bone spur complexes that contacted the exiting nerve roots. Id. He stated the lumbar MRI showed facet arthropathy and degenerative changes at ¶ 3-4, L4-5, and L5-S1, but no disc herniation or stenosis. Id. Plaintiff described her pain as a five on a 10-point scale and indicated it was exacerbated by sitting and looking down. Id. Dr. Johnson observed Plaintiff to be 5'3” tall and to weigh 260 pounds. Tr. at 413. He noted that Plaintiff was diffusely tender in the midline, had limited ROM of her neck and low back, and reported pain with extension of her arm at the shoulder. Id. His impressions were cervical spondylosis with stenosis most pronounced at ¶ 5-6 and degenerative disc disease at ¶ 3-4, L4-5, and L5-S1. Id. He recommended that Plaintiff obtain an updated MRI of her cervical spine to determine if surgery was indicated. Id. He stated possible treatment options for the lumbar spine including ESIs, rhizotomy, and spinal cord stimulator, but indicated the MRI results did not suggest surgery would be beneficial. Id. He did not feel that Plaintiff had reached maximum medical improvement and did not believe she should return to work at that time. Id.

         Thomas D. Wooten, Jr., M.D. (“Dr. Wooten”), administered a lumbar ESI on May 7, 2012. Tr. at 497.

         On May 15, 2012, a computed tomography (“CT”) scan of Plaintiff's cervical spine showed no acute fracture, dislocation, or significant degenerative changes. Tr. at 431.

         Plaintiff reported increased pain in her neck, right shoulder, and right forearm on May 25, 2012. Tr. at 460. Dr. Aymond observed Plaintiff to have normal sensation to light touch and pinprick in the C5-6 and C7 dermatomes and tenderness to palpation of the posterior aspect of the neck. Id. He noted Plaintiff's complaints of radicular pain into the right upper extremity. Id. He assessed cervical radiculopathy, low back pain, and morbid obesity. Id. He referred Plaintiff for a new MRI of the cervical spine and authorized her to remain out of work until after he had an opportunity to review her MRI results. Tr. at 463 and 463. Plaintiff subsequently received a second lumbar ESI. Tr. at 494.

         Plaintiff underwent an MRI scan of her cervical spine on June 14, 2012, that showed no disc herniation or significant central stenosis. Tr. at 415. However, it indicated an annular bulge at ¶ 5-6 that combined with reversal of the normal curvature to cause ventral canal narrowing and minimal ventral cord flattening. Id. It also showed uncovertebral hypertrophy with mild bilateral foraminal narrowing. Id.

         Plaintiff presented to Beth Price, M.D. (“Dr. Price”), for a complete physical examination on June 18, 2012. Tr. at 420. Dr. Price noted sinus tachycardia. Tr. at 422. She observed Plaintiff to be 63 inches tall and to weigh 260 pounds. Tr. at 421. Plaintiff requested Phentermine for weight loss, but Dr. Price declined to prescribe the medication in light of Plaintiff's abnormal electrocardiogram (“EKG”). Tr. at 420 and 422. She advised Plaintiff to eliminate diet sodas and to find a pool for exercise. Tr. at 422.

         Plaintiff followed up with Dr. Aymond to review the results of the cervical MRI scan on June 19, 2012. Tr. at 464. Dr. Aymond stated the MRI showed a central disc bulge at the C5-6 level. Id. Plaintiff continued to report aching pain in her low back, neck, interscapular area, and bilateral shoulders. Id. Dr. Aymond observed Plaintiff to have limited cervical rotation and slightly diminished sensation in the right C6 dermatome distribution. Id. He recommended anterior cervical discectomy and fusion at the C5-6 level and referred Plaintiff to Edward Nolan, M.D. (“Dr. Nolan”), for management of her low back pain. Id. He indicated Plaintiff should remain out of work until after a six-week follow up visit. Tr. at 468.

         Plaintiff presented to Dr. Nolan with complaints of pain in her neck, low back, left hip, and tailbone on July 17, 2012. Tr. at 672. She indicated her pain was aggravated by sitting, walking, and driving. Id. She stated her pain affected her sleep and physical and social activities. Id. Dr. Nolan observed Plaintiff to have intact and symmetrical cranial reflexes, slightly reduced deep tendon reflexes, decreased sensation to light touch in her right upper extremity and left lower extremity, normal coordination, grossly intact muscle strength, normal tone, antalgic gait, and negative SLR test. Tr. at 673. Plaintiff reported moderate pain from her bilateral cervical paraspinous muscles into the bilateral trapezius muscles; moderate cervical radicular pain with ROM in the right C5, C6, and C7 nerve distribution to the hand; moderate pain in her bilateral lumbar paraspinous muscles; and tenderness to palpation overlying the L3-4, L4-5, and L5-S1 facet joints. Id. Dr. Nolan assessed lumbar facet arthropathy and cervical radiculopathy. Id. He indicated he would take over management of Plaintiff's medications and would administer a lumbar facet injection after receiving authorization from the workers' compensation carrier. Id.

         On August 7, 2012, Plaintiff reported that she was unable to sit for more than 30 minutes without experiencing severe pain in her lower back and coccyx. Tr. at 471. She continued to complain of pain in her posterior neck and interscapular area and upper extremity dysesthesias. Id. Dr. Aymond observed Plaintiff to have limited mobility of the cervical spine, normal motor strength, and slightly diminished sensation in the C6 dermatome distribution. Id. He indicated Plaintiff would proceed with cervical fusion and authorized her to remain out of work based on her inability to sit for greater than 30 minutes at a time. Id. However, on August 15, 2012, he authorized Plaintiff to return to work with the ability to change positions every two to four hours as needed. Tr. at 475.

         Dr. Nolan administered facet lumbar injections to Plaintiff's bilateral L3-4, L4-5, and L5-S1 areas on August 22, 2012. Tr. at 670.

         Plaintiff complained of pain in her neck and low back on September 6, 2012. Tr. at 666. She reported greater than 80 percent initial pain relief from lumbar facet injections, but indicated the pain had slowly returned to her right lower back. Id. Dr. Nolan noted moderate pain in Plaintiff's bilateral cervical paraspinous muscles to the shoulder, moderate pain in the right lumbar paraspinous muscles, and moderate pain in the coccyx. Tr. at 666-67. He indicated he would treat Plaintiff's lumbar facet arthropathy and coccydynia with injections during her next visit. Tr. at 667.

         Dr. Nolan administered facet lumbar injections at the bilateral L3-4, L4-5, and L5-S1 levels on September 25, 2012. Tr. at 664.

         On October 10, 2012, Plaintiff reported that she had received greater than 60 percent initial pain relief from the lumbar facet injections, but indicated the pain had returned. Tr. at 660. Dr. Nolan noted mild-to-moderate pain to palpation in the bilateral lumbar paraspinous muscles and moderate pain to palpation in the left piriformis muscle over the sciatic nerve. Tr. at 661. He indicated he would administer transforaminal ESIs during Plaintiff's next visit. Id.

         Plaintiff presented to Curtis Worthington, M.D. (“Dr. Worthington”), for an IME on October 23, 2012. Tr. at 598. Dr. Worthington observed Plaintiff to have normal station and gait; to be able to walk on her heels and toes without difficulty; to be tender to palpation along the lower lumbar spinous process, sacrum, and cervical spine; to demonstrate full ROM; to have normal tone, bulk, and strength in all muscle groups; to have no sensory deficits; and to demonstrate symmetrical reflexes. Id. He reviewed Plaintiff's imaging studies and interpreted them to show mild multi-level degenerative changes to the lumbar spine and degeneration with disc collapse, increased angulation, and some bulging at the C5-6 level. Tr. at 599. He indicated Plaintiff had no compression of the spinal cord or clear compression of the nerve roots. Id. He opined that Plaintiff had a multifactorial pain syndrome that was affected by fibromyalgia and obesity. Id. He recommended a bone scan to rule out a lesion to the lumbar spine and a cervical discogram to determine if C5-6 discectomy and fusion would be beneficial. Id.

         Dr. Nolan administered lumbar transforaminal ESIs to Plaintiff's bilateral L4 and L5 nerve roots on October 24, 2012. Tr. at 658.

         Plaintiff complained of low back pain on December 19, 2012. Tr. at 654. She indicated that her last injection had provided greater than 80 percent initial pain relief, but that the pain had returned. Id. She reported that sitting and looking up and down exacerbated her pain. Id. Dr. Nolan refilled Plaintiff's medications and indicated he would administer additional injections during her next visit. Tr. at 655.

         On January 11, 2013, CT discography of Plaintiff's cervical spine revealed anterior and posterior endplate overgrowth that extended throughout the annulus in a manner consistent with degenerative disc disease. Tr. at 485. It further showed mild canal narrowing secondary to disc osteophyte complex and likely minimal left and right foraminal encroachment. Id. Plaintiff underwent a whole body scan on January 16, 2013, that revealed no abnormality in the spine. Tr. at 481.

         On January 22, 2013, Dr. Worthington explained to Plaintiff that her pain was multifactorial as a result of neck and low back pain and fibromyalgia, as opposed to being related entirely to the lesion at ¶ 5-6. Tr. at 584. However, he indicated that neck surgery would likely reduce Plaintiff's neck pain and arm discomfort. Id. He recommended C5-6 anterior discectomy with decompression of the spinal cord and nerve roots. Tr. at 585.

         Dr. Nolan administered injections to Plaintiff's coccyx and lumbar spine on January 23, 2013. Tr. at 651-52.

         Plaintiff returned to Dr. Worthington to review the operative plans on February 27, 2013. Tr. at 579. Dr. Worthington explained that he was “less confident in the success of the operation” because Plaintiff lacked radiculopathic and myelopathic signs and symptoms. Id. He indicated that Plaintiff would be admitted for anterior cervical discectomy at ¶ 5-6. Tr. at 580.

         On March 7, 2013, Dr. Worthington and Michael C. Noone, M.D. (“Dr. Noone”), performed anterior cervical discectomy and fusion with instrumentation at the C5-6 level. Tr. at 499-502. Plaintiff presented for a postoperative visit on March 27, 2013, and reported that her headaches and the numbness and pain in her arms had resolved. Tr. at 577. She indicated she was better able to use her upper extremities for a longer period of time, but continued to be hoarse, cough, choke, and feel short of breath. Id. Dr. Worthington noted that Plaintiff continued to experience “a little bit of decreased range of motion, some mild focal cord problem, and difficulty sleeping, ” but was doing very well overall. Id. Plaintiff's wound was clean, dry, and well-healed and she demonstrated no neurological deficits. Id. Dr. Worthington prescribed Ativan for sleep and indicated Plaintiff should begin physical therapy in three weeks. Id.

         On April 9, 2013, Plaintiff reported that she had received a 30-day supply of Oxycodone, Flexeril, and Lorazepam following her surgery, but had not finished all of the pills. Tr. at 647. She indicated the injections she received in January had helped her coccygeal pain, but had not worked as well for her low back pain. Id. Dr. Nolan noted no abnormalities on physical examination. Tr. at 647 and 649. He indicated he would administer injections to Plaintiff's low back and coccyx during her next visit. Id.

         Plaintiff reported pain in her low back and tailbone on May 1, 2013. Tr. at 645. Dr. Nolan administered lumbar facet and coccyx injections. Tr. at 645-46.

         Plaintiff presented for a physical therapy evaluation on May 6, 2013. Tr. at 531. She reported a significant decrease in cervical symptoms following her surgery, but indicated she continued to be awakened by neck stiffness a couple of times per night when she took less than a whole Ativan tablet. Id. She reported she took Lortab an average of once a week when she felt like she had overexerted herself. Id. She described her pain as ranging from a four to a six on a 10-point scale and indicated it was exacerbated by rotating her neck to the right, repetitively turning her head, and riding in a car. Id. She reported that her headaches had stopped and she was able to read again. Id. Physical therapist Julie Black indicated Plaintiff demonstrated good rehab potential. Tr. at 532. She scheduled Plaintiff for two-to-three sessions per week for four weeks. Id.

         Plaintiff followed up with Dr. Worthington on May 29, 2013, and reported that her neck was “as good as it can be.” Tr. at 575. She continued to complain of severe pain in her tailbone. Id. Dr. Worthington observed that Plaintiff's surgical wound was well-healed. Id. He referred Plaintiff for a new MRI of her lumbar spine. Id.

         Plaintiff reported minimal relief from injection therapy on July 11, 2013. Tr. at 644. She complained of moderate coccygeal pain that intensified with sitting and moderate bilateral lumbar paraspinous muscle pain. Tr. at 643. Dr. Nolan continued Plaintiff's medications pending results of an MRI. Tr. at 644.

         On July 15, 2013, an MRI scan of Plaintiff's lumbar spine showed an L5-S1 disc bulge with annular tear that caused moderate right and ...

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