United States District Court, W.D. Louisiana, Lafayette Division
REPORT AND RECOMMENDATION
C. MICHAEL HILL, Magistrate Judge.
This social security appeal was referred to me for review, Report and Recommendation pursuant to this Court's Standing Order of July 8, 1993. Ronald Lee LeDoux, born November 28, 1965, filed an application for a period of disability, disability insurance benefits and supplemental security income on May 20, 2011, alleging disability as of September 15, 2008, due to back pain, borderline intellectual functioning based on lack of education, and alcohol and drug abuse in remission.
FINDINGS AND CONCLUSIONS
After a review of the entire administrative record and the briefs filed by the parties, and pursuant to 42 U.S.C. § 405(g), I find that there is substantial evidence in the record to support the Commissioner's decision of non-disability and that the Commissioner's decision comports with all relevant legal standards. Anthony v. Sullivan, 954 F.2d 289, 292 (5th Cir. 1992).
In fulfillment of F.R.Civ.P. 52, I find that the Commissioner's findings and conclusions are supported by substantial evidence, which can be outlined as follows:
(1) Records from University Medical Center ("UMC") dated April 30, 2009 to July 12, 2010. On July 1, 2009, claimant complained of neck and upper back pain after falling off of a roof six days prior. (Tr. 259). A thoracic spine series showed mild anterior wedging of mid-thoracic vertebral bodies with kyphosis and moderate endplate spurring greatest anteriorly. (Tr. 242). Lumbar spine x-rays showed mild lower lumbar spondylosis. (Tr. 258).
An MRI of the cervical spine dated July 16, 2009, showed posterior bulging of the C3-4 disc which minimally impressed the thecal sac. (Tr. 241). The nerve root foramina were patent. A lumbar spine MRI dated July 16, 2009, showed no significant findings. (Tr. 255).
On August 5, 2009, claimant complained of back pain not relieved by Tylenol. (Tr. 249). On examination, his strength was 5/5 in the upper and lower extremities. The assessment was back pain, for which he was prescribed Tramadol. (Tr. 250).
(2) Records from American Legion Hospital dated March 15, 2011. Claimant complained of head, neck, and lower back pain after a motor vehicle accident. (Tr. 282). Lumbar and cervical spine x-rays were normal. (Tr. 286-87). The impression was cervical/lumbar sprain/strain. (Tr. 283). He was prescribed Ibuprofen, Tramadol and Baclofen as needed for pain. (Tr. 290).
(3) Records from Dr. Robert Franklin dated March 15, 2011 to June 13, 2011. On March 28, 2011, claimant complained of severe and constant neck, upper back and low back pain, and mild to moderate and intermittent headaches. (Tr. 299). He was taking muscle relaxers and Ibuprofen. On physical examination, he mobilized antalgically, particularly from the cervical region.
On cervical exam, claimant's posture was poor. (Tr. 300). He guarded with cervical range of motion, and complained significantly of pain on range of motion and palpation. He had spasm in the left superior trapezius muscle group.
Claimant guarded on left shoulder exam. On lumbar exam, he lacked lumbar extension, and complained of pain on range of motion and palpation. Neurologically, he was intact with regard to motor, reflexes, and cranial nerves.
Dr. Franklin's impression was cervical and lumbar strain, possible underlying spinal pathology, and headaches. He recommended conservative treatment. He prescribed Celebrex, Flexeril, and Lortab. Claimant was temporarily disabled from employment.
An MRI dated April 15, 2011, showed mild levoscoliosis of the cervical and upper thoracic spine; mild right uncinate hypertrophy at C2-3, mild right uncinate hypertrophy at C3-4, minimal diffuse annular bulges at C4-5 and C5-6, minimal narrowing of the right C3-4 foramen, and no central canal or foraminal stenosis. (Tr. 292). A lumbar MRI showed mild levoscoliosis of the lumbar spine; a small focal left foraminal disc protrusion containing an annular fissure at L3-4, minimal diffuse annular bulge with a left foraminal annular fissure at L4-5, a small focal midline disc protrusion containing an annular fissure at L5-S1, and no central or foraminal stenosis. (Tr. 293).
On April 18, 2011, claimant was minimally improved. (Tr. 298). The cervical MRI revealed underlying scoliosis, as well as multilevel degenerative changes and disc bulges. The lumbar MRI revealed disc protrusions, two disc herniations, underlying degenerative changes, annular fissures and scoliosis.
Claimant requested to be released to light duty. Dr. Franklin honored that request.
On May 16, 2011, claimant's symptoms persisted. (Tr. 297). His exam was unchanged. Dr. Franklin gave him a Lyrica trial. He stated that claimant was temporarily disabled from employment.
On June 13, 2011, claimant continued with pain and guarded range of motion. (Tr. 296). Dr. Franklin titrated his Lyrica dose. He stated that ...