Summary: 51 year old male with long work history and two neck surgeries who is now on long term pain management
Client profile: my client is 51 years old with a high school education. His past work was as a machine operator in which he loaded raw materials into a machine that would create pellets for use in construction. Four years prior to his alleged onset date in 2018 my client underwent a laminectomy and fusion in his cervical spine. He was able to return to work for several years but by 2018 he was experiencing numbness and weakness in his neck, radiating into an arm. In the fall of 2018, the numbness became so severe that he needed a second cervical surgery on an emergency basis. Following surgery, my client continued to experience numbness and weakness in his neck and upper extremities, as well as balance and weakness in his lower extremities. He is no longer a surgical candidate and has been referred for long term pain management.
Claim background: my client filed for SSDI in the fall of 2019 alleging an onset date in the fall of 2018. A telephone hearing was held in early 2021.
Factors in our favor:
- my client has a long and consistent work history
- the judge assigned to our case is reasonable and fair with a higher than average approval rate
- my client has permanent nerve damage in the cervical (neck) region due to spinal stenosis and he has not gained relief despite two surgeries
- there is objective MRI evidence of spinal stenosis
- the pain medications prescribed for my client are powerful and have side effects of drowsiness and cognitive impairment
- my client was 49 at onset and turned 50 several months after onset
Factors not in our favor:
- because of COVID and loss of insurance my client has not had much recent medical treatment
- we were not able to obtain a functional capacity evaluation form
My strategy: I felt that this was a very strong case because of my client’s age, long and consistent work history and loss of function following two cervical surgeries. Generally speaking a disability claimant who has undergone two neck or back surgeries and has been referred to long term pain management because the 2nd surgery did not restore function is likely to be approved. I prepared a detailed opening statement explaining the history of my client’s medical treatment and current functioning and noted his age and work history.
Hearing Report: this hearing lasted about 15 minutes. I gave a longer than normal opening statement and the judge asked my client about his daily activities as well as his symptoms. My client did a good job explaining that he needed one to three hours on his couch or recliner every day because of medication side effects but that he tried to help his wife with cooking and daily activities when he was able. In our preparation I encouraged him to present himself as a reluctant and sincere person and he did an excellent job describing his current functioning.
After the judge finished with her questions, she advised me that she had enough information to proceed with vocational expert testimony and did I have any objections (I did not). The judge then asked the vocational witness to describe my client’s pas work. Then she asked one hypothetical question to the vocational witness:
Assume a hypothetical person with the same work history, medical history and education as the claimant and assume that this person is limited to light work with the following limitations:
- he would need a sit/stand option at work with the ability to alternate positions every 30 minutes
- he would need a job that requires no overhead lifting
- he would need to take frequent unscheduled breaks
Based on this profile could such a person perform the claimant’s past work or any other work in the regional or national economy
The vocational witness responded that no jobs exist which would allow for this level of limitation.
The judge then turned to me and said that she assumed I had no questions for the VE and that she did not expect that I needed to give a closing argument.
I did feel that the hypothetical question was a bit vague but since I was winning I decided to say nothing.
Conclusions: the judge will approve this case. This is an example of a winning case profile – a 50 year old claimant with a long and consistent work history whose neck pain has not been resolved following two surgeries and who is now on long term pain management.