What is spondylolisthesis, the back condition that derailed Luigi Mangione’s life?

What a difference a fraction of an inch can make.

Having one of the 33 bones in his spine out of alignment by less than half an inch apparently diminished Luigi Mangione’s quality of life to the point that his lower legs felt like they were on fire. At other times, the 26-year-old charged with murdering the chief executive of UnitedHealthcare seesawed between pain and numbness in his lower back and genital area.

Social media posts believed to be written by Mangione indicated he was diagnosed with spondylolisthesis, a back condition that emerged during childhood and became debilitating after an accident during a surfing lesson in 2022.

“My back and hips locked up after the accident,” wrote a Reddit user whose biographical details align with Mangione’s. The user, whose account has been deleted, also complained that “intermittent numbness has become constant.”

“I’m terrified of the implications,” the user wrote, according to CNN.

Mangione is accused of fatally shooting Brian Thompson outside a Midtown Manhattan hotel last week, and evading capture for five days. His attorney said the Ivy League graduate intended to plead not guilty to the murder charge.

Back pain isn’t the only health condition that plagued Mangione — the Reddit account included posts about brain fog and Lyme disease — but spondylolisthesis appears to have been the most taxing.

There are many reasons why a segment of the spine can move out of alignment.

Spondylolisthesis (pronounced spawn-duh-low-lis-THEE-sus) can begin before birth if the spine doesn’t develop properly in utero. Or it can occur suddenly if an accident or injury thrusts one of the vertebrae out of position.

A fracture in the part of the bone that links the vertebrae together can become so big that a segment of the spine can’t be held in place. A bone-weakening disease like osteoporosis or even a spinal tumor can disturb the vertebrae’s alignment as well.

Most often, spondylolisthesis is a consequence of aging. The older we get, the more the cushiony disks that separate the vertebrae thin out. When the bones aren’t held as tightly in place, it’s easier for one to wind up where it doesn’t belong.

Any part of the spine can be affected by spondylolisthesis, but it’s most common in the lower back. (The Reddit user who is believed to be Mangione indicated that his misaligned bone was at the bottom of his lumbar spine, just above the pelvis.)

Wherever it occurs, having a spinal bone out of place can affect the nerves around the spine. Back pain is a typical symptom, but the pain can spread all the way down the legs and to the feet if one of the sciatic nerves is involved. The discomfort can also manifest as a pins-and-needles tingling sensation.

In Mangione’s case, the symptoms seem to have kicked into high gear while surfing in Hawaii in 2022. The Reddit user said he “experienced sciatica for the first time” while on the water, according to Business Insider, though it’s not clear whether the painful condition caused his accident or resulted from it.

Things went from bad to worse a few weeks later, when he “slipped on a piece of paper,” he said. “My right glute locked and right leg shut down for a week. Couldn’t support any weight on it.”

He also experienced a “near-constant burning/twitching in both ankles/calves.”

Pain isn’t the only symptom of spondylolisthesis. With a part of the spine out of place, patients may have back stiffness, be unable to stand for more than a few minutes, or have trouble walking.

These problems can get worse if left untreated. Other potential complications include urinary or bowel incontinence, the Cleveland Clinic says.

Initial treatment usually includes rest to relieve stress on the spine and painkillers like Advil, Motrin, Aleve or Tylenol to help with pain and reduce inflammation. If over-the-counter medications aren’t enough, doctors may prescribe corticosteroid medications or a coritsone injection.

Once the time for rest has passed, specific exercises can strengthen muscles in the abdomen and lower back to better support the spine. A brace or corset may also be needed, especially if the problem was caused by a fracture that needs to heal.

The only way to actually move the bone back into place is with surgery, and that may be necessary if serious problems persist.

The goal of the surgery depends on the cause of the patient’s spondylolisthesis, according to the American Academy of Orthopaedic Surgeons.

If a fractured bone is to blame, surgeons can shore it up by fusing it to another vertebrae using screws and rods. Mangione had spinal fusion surgery in 2023 after living with pain for a year and a half.

He shared a picture of a post-operative X-ray with one of his former roommates from his time in Hawaii. The image “looked heinous, with just giant screws going into his spine,” the ex-roommate, R. J Martin, told CNN.

On Reddit, the user believed to be Mangione reported that the surgery was a success. “Within 7 days of the fusion I was on zero pain meds,” he wrote, according to ABC News.

If a fracture isn’t the problem but a misaligned disk is compressing nearby nerves, surgeons may perform a laminectomy. That procedure removes part of the bone and nearby ligaments to create more space for the nerves.

Sometimes surgical patients have both treatments, the academy says.

Although Mangione seemed pleased with the results of his surgery, he was not happy that it took so long for him to receive it. The Reddit user said he had feared he would be “destined to chronic pain and a desk job for the rest of my life.”

He advised other Reddit users to exaggerate their symptoms — such as pretending they couldn’t lift the front of their foot or urinating in their clothes on purpose — in order to get surgery sooner.