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Lambert v. Berryhill

United States Court of Appeals, Seventh Circuit

July 19, 2018

Paul Lambert, Plaintiff-Appellant,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant-Appellee.

          Argued February 28, 2018

          Appeal from the United States District Court for the Eastern District of Wisconsin. No. 15-C-1548 - William C. Griesbach, Chief Judge.

          Before Manion, Sykes, and Hamilton, Circuit Judges.

          Sykes, Circuit Judge.

         Paul Lambert appeals the denial of Disability Insurance Benefits for chronic back pain. The Social Security Administration denied his application initially and on reconsideration, and an administrative law judge ("ALJ") concluded that Lambert suffers from degenerative disc disease that is severely impairing but not disabling. Lambert challenges the ALJ's decision to give little weight to the most recent opinions of his treating neurosurgeon and to discredit his own testimony about the severity of his pain and extent of his limitations. We reverse and remand for further agency proceedings.

         I. Background

         Lambert applied for benefits in 2012 at age 41 alleging disabling lower back pain since 2011, an onset date that he later amended to 2013. Yet his back problems started long before then. In 2004 discs in his lumbar spine were surgically fused with a rod. In 2008 surgeons repaired the rod. Still, Lambert held several jobs over the years.

         In 2010 Lambert began experiencing back pain "most of the time" and thereafter also had "intermittent" pain down his left leg that often caused him to fall. By late 2012 Lambert had tried various treatments, including steroid injections in his spine and pelvis, chiropractic care, medication, and physical therapy. Nothing produced lasting relief, though hydrocodone helped ease the pain. Medical imaging revealed no postsurgical complications or other explanation for his persistent pain. Several neurosurgeons found the cause unclear; three said further surgery was not an option.

         In September 2012 a pain specialist attributed Lambert's pain to degenerative disc disease or joint disease of the lower lumbar spine. Months later he diagnosed Lambert with failed back syndrome (meaning he experienced continuous pain despite surgeries) and recommended that he accept his chronic pain and proceed with a pain-management program instead of seeking a surgical cure. The pain specialist also recommended that Lambert consider behavioral therapy to learn coping skills. Lambert followed this advice, but in early 2013 the pain specialist referred him to a neurosurgeon to find the source of the left-leg pain that by this time was causing daily falls.

         Neurosurgeon Kamajit Paul began treating Lambert in June 2013 and initially recommended a conservative course of steroid injections to determine if his pain was caused by dysfunction in the left sacroiliac joint. (The sacroiliac joints connect the pelvis to the lower spine and support the weight of the upper body when a person stands. Sacroiliac Joints, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/sacroiliiitis/multimedia/sacroiliac-joints/img-20005962 (last visited June 28, 2018).) The pain specialist administered three injections but continued advising Lambert to accept his chronic pain and moderate his activities. Because the injections provided only several hours of relief, Dr. Paul believed Lambert had dysfunction in his left sacroiliac joint and recommended surgery to fuse it. But he cautioned that the surgery offered no guarantee of improvement and that Lambert would still experience some back and leg pain and would "never be 100%."

         Dr. Paul performed the left-joint fusion in October 2013, and Lambert's condition initially started to improve. In November Lambert reported minimal pain. After a month of physical therapy, he underwent a functional assessment in January 2014. He was able to walk without an assistive device and reported "improved function at home and in the community." His physical therapist recommended allowing him to return to work with some lifting restrictions, and Dr. Paul released Lambert to light-duty work.

         But Lambert's relief was short-lived. In February 2014 he returned to Dr. Paul, now reporting pain on his right side. Dr. Paul was "not sure what [was] happening" and sent Lambert back to his pain specialist. Testing revealed potential dysfunction in the right sacroiliac joint.

         In late March 2014, Dr. Paul completed an assessment of Lambert's functional abilities. He diagnosed bilateral joint dysfunction and stated that Lambert experienced continued pain in his right sacroiliac joint and lower back. He opined that in a competitive work situation, Lambert could sit for at least six hours out of eight, stand for 30 minutes at a time (up to two hours total), and walk one block at a time (if allowed to shift between these positions at will). Dr. Paul also noted, however, that Lambert's prognosis was guarded and that he "may develop problems in the upper lumbar spine."

         In April 2014 Dr. Paul surgically fused Lambert's right sacroiliac joint. Lambert returned to physical therapy and in early June reported that his preoperative pain had resolved. But later that month Lambert told his physical therapist that the pain on the left side of his lower back had returned; he said it was minimal but interfered with sleep. A week later Lambert said the pain had worsened and now prevented him from walking as far as he could just weeks before. In July 2014 Lambert told Dr. Paul that he had been experiencing pain-exacerbated by activity-for as long as four weeks. X-rays revealed intact surgical hardware ...


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