John F Kennedy: “I think the doc should have read just one more book before picking up the saw”

US president John F Kennedy is famous in equal parts for his youth, his diplomatic skill and his untimely demise. Less well-known are the multitude of health problems that dogged him since childhood. A historical review published in the Journal of Neurosurgery: Spine has traced his longstanding issues with back pain, the four surgeries attempting to solve them, and their potential impact on his death. The history of John F Kennedy’s spine offers a cautionary tale of the perils of failed back surgery.

The start of Kennedy’s back troubles likely began at a 1937 Harvard University (Cambridge, USA) football match, during which he sustained an injury. In 1940, orthopaedic spine specialist Gilbert “Ned” Haggart (Lahey Clinic, Boston, USA) diagnosed a “very unstable sacral joint”, for which he prescribed conservative care, and considered sacroiliac fusion.

Kennedy’s back pain continued, and contributed to the failure of a physical examination for military service. Eventually, the political connections of his US ambassador father helped him to enter the US Naval Reserve in 1941. Marius Nygaard Smith-Peterson, a Norwegian-born orthopaedic surgeon based at the time at Harvard University did not believe the pain to be generated by a disc, or to be consistent with sciatica. At this point, surgical intervention was considered unnecessary, and Kennedy was declared fit for duty in 1942.

It was during this period of naval service in the Pacific theatre that Kennedy famously towed another crewman for five hours to a nearby island, following a collision between Kennedy’s boat and a Japanese destroyer. This incident is likely to have considerably worsened his back problems.

Upon his return home, Kennedy’s first back surgery was performed by orthopaedist Ralph Gormley at the Mayo Clinic (Rochester, USA), following an air myelogram. Whilst the Mayo Clinic team decided not to perform the procedure—given uncertainty around “the diagnosis of a protruded disc”—Kennedy underwent an L4–L5 laminotomy and L5–S1 discectomy at the Lahey Clinic in 1944.

Initially relieved of his pain, two weeks after the procedure, when attempting to walk, Kennedy suddenly experienced severe spasms. According to surgeon John Poppen, one of Kennedy’s nerves appeared inflamed upon exploration, and the surrounding disc material appeared abnormally soft.

“I have had nine other patients in a series of over five hundred ruptured intervertebral discs with a similar experience,” Poppen wrote six weeks after the procedure. “I am indeed sorry that this had to happen with Lieutenant Kennedy.”

Following referral to Chelsea Naval Hospital (Suffolk County, USA), neurosurgeon James White questioned the decision to perform the surgery on the basis of an air myelogram, rather than one using the radiocontrast agent iophendylate.  The iodobenzene was only recently introduced and considered risky. (Later, hundreds of patients worldwide who developed arachnoiditis after treatment with iophendylate filed lawsuits against the distributors.)

T Glenn Pait and Justin T Dowdy, authors of the present historical review, assessed preoperative and postoperative films of Kennedy’s spine, concluding that Kennedy had “a radiographically normal-appearing lumbar spine” in December 1944.

It was at this point that Kennedy wrote, “In regard to the fascinating subject of my operation … I think the doc should have read just one more book before picking up the saw.”

Between 1946 and 1952, Kennedy experienced the death of his brother, a diagnosis of Addison’s disease, and an ascent through the US political system—he was elected to congress and eventually the US Senate.  During this time, Kennedy tried to treat his back pain using a brace, back rubs and hot baths.

In spite of the high risk imposed by his Addison’s disease, Kennedy decided to undergo a lumbosacral fusion operation at the Hospital for Special Surgery (New York City, USA). Radiographs reviewed by Plait and Dowdy showed “marked loss of height at the previously surgically treated L5–S1 disc space (approximately 70%) when we compared it with the most recent previous film from 1944.”

Leading orthopaedic surgeon Philip Wilson implanted his own invention during the lumbosacral fusion procedure. The Wilson plate consisted of a cobalt-chromium alloy implant “curved to mimic lumbar lordosis and secured to the spinous processes with horizontally-oriented locking bolts,” Plait and Dowdy report.

The plate was visible from L5–S2 on radiographs, attached by three transverse bolds, “along with a defect at the left sacroiliac joint consistent with bone graft placement.”

Whilst the Hospital for Special Surgery records proved elusive, Plait and Dowdy reviewed an anonymous case report of Kennedy’s procedure. Although John F Kennedy did not experience an Addison’s-related crisis, he did develop a urinary tract infection following the procedure. Described as a “minor” complication in the case report, Plait and Dowdy write that, in fact, the infection led to a coma so severe Kennedy was read his last rites.

Kennedy’s associates later described a staphylococcal infection present in his surgical wounds. “The area where they cut into his back never healed. It was oozing blood and pus all the time … now and then a piece of bone would come out of the wound. His pain was excruciating,” advisor LeMoyne Billings reported. The Wilson plate and its screws were removed in 1955 as a result of continued infection.

Following this series of failed surgeries and major complications, Kennedy was treated by pharmacologist Janet Travell of the New York Hospital-Weill Cornell Medical Center (New York City, USA). Trevall began what would precede hundreds of procaine trigger-point injections to help treat his continuing back pain. She also “introduced Kennedy to what would, in a few short years, become a symbol of his presidency—the rocking chair,” Plait and Dowdy noted.

Further conservative measures—including a heel lift, for what may have been pelvic obliquity and leg-length discrepancy, and muscle-strengthening exercises—substantially reduced Kennedy’s back pain.

Kennedy’s fourth and final spinal surgery took place in 1957, again at the Hospital for Special Surgery, following the development of a superficial lumbar abscess. Preston Wade performed a wound exploration “markedly less invasive” than Kennedy’s previous operations. Samples confirmed the presence of staphylococcus aureus. He was discharged 19 days later.

Pharmacologist Travell argued that chronic osteomyelitis could be the cause of Kennedy’s left sacral abnormalities, but authors Plait and Dowdy write that postoperative radiographs suggest they “are more consistent with postoperative changes from the sacroiliac arthrodesis performed during the fusion procedure.”

Kennedy’s health issues became a focal point of his 1960 presidential race, during which he sought the help of “Dr FeelGood” Max Jacobson, a German physician working in New York City, for a resurgence in back pain. Jacobson prescribed a “vitamin cocktail” containing methamphetamine.

The now-president Kennedy injured his back again in 1961, planting a tree in Ottawa, Canada, during which he returned to several conservative pain relief methods, and increased his use of Jacobson’s cocktail.

According to Plait and Dowdy, “The poor state of his back and its effects on [his] overall well-being may have been a considerable and negative impact on the President’s performance at the crucial Vienna summit with Soviet Premier Nikita Krushchev.”

By the Autumn of 1961, Kennedy’s healthcare had been taken over by White House physician Rear Admiral George C Burkley. With the assistance of Austria-born orthopaedist Hans Kraus, Kennedy entered into a successful programme of regular, intense exercise, massage and heat therapy.

According to the authors’ assessments of preserved radiographs, Kennedy did not suffer from a congenital unstable lumbosacral joint, and did not endure a steroid-induced compression fracture, as reported by biographer Robert Dallek. Loss of height was likely due to his initial discectomy surgery. In 1962, radiographs show neural foraminal narrowing at L5-S1, and “near complete loss of lumbar lordosis, which was not evident on films 18 from years prior.”

“Some evidence of fusion of the L5-S1 facet joints bilaterally” suggests that his 1954 surgery was at least somewhat successful.

At the time of John F Kennedy’s assassination he was wearing a brace for his back. This has been speculated by authors including John Lattimer (Columbia University, New York City, USA) to have “returned the president to an upright position after the potentially survivable first shot and back into Lee Harvey Oswald’s scope sight.” However, according to Plait and Dowdy’s review, “it is by no means assured that President Kennedy could have survived the initial neck wound,” particularly given his chronic corticosteroid use.

While debate remains as to the impact of his bracing on his death, the authors note that this remains “a fascinating and evocative footnote given its potential role in altering the course of US and world history.”

Kennedy’s multifactoral, longstanding back pain was, according to authors, the result of “an unfortunate pattern of treatment and outcomes that contemporary spine surgeons struggle with at times.” This course of events may have been affected by the “VIP care” Kennedy received, notably with the conservative choice of an air myelogram.

“Personally,” the authors conclude, “JFK remains a study in the complexity of human nature—an affluent political scion turned war hero, a serial philanderer and methamphetamine user, a civil-rights supporter and initiator of the Vietnam War who was both the youngest man elected president in the nation’s history and perhaps the twentieth century’s least healthy one.”

A version of this article was originally published in issue 44 of Spinal News International.