The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 5

The Orthopaedic Forum | May 01, 2006

Failed Spine Surgery Syndrome in the Life and Career of John Fitzgerald Kennedy

Robert A. Hart, MD¹

¹ Department of Orthopaedic Surgery, OP31 Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail address: hartro@ohsu.edu

View Disclosures and Other Information

Note: The author acknowledges the assistance of Seymour Hersh, Robert Dallek, PhD, Malcolm Perry, MD, and Philip Wilson Jr., MD, as well as the staff of the John F. Kennedy Library, especially Allan Goodrich and Maryrose Grossman.

The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 May 01;88(5):1141-1148. doi: 10.2106/JBJS.E.01077

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Extract

John F. Kennedy suffered the effects of multiple illnesses throughout his adult life. His diagnoses included chronic colitis, Addison disease, and degenerative disease of the lumbar spine1-11. The lumbar spine problems began in his early twenties and resulted in four surgical interventions over the course of his life. Despite these interventions, severe low-back pain plagued him more or less continually until his death. The nature of his diagnosis and treatment has remained unclear despite the large volume of written material dedicated to his life. In this article, the available medical and radiographic records are analyzed in an effort to clarify his diagnosis and treatment course, as well as to examine the effects of the lumbar spine disease on his life and political career.

Figures in this Article

John F. Kennedy suffered the effects of multiple illnesses throughout his adult life. His diagnoses included chronic colitis, Addison disease, and degenerative disease of the lumbar spine^1-11. The lumbar spine problems began in his early twenties and resulted in four surgical interventions over the course of his life. Despite these interventions, severe low-back pain plagued him more or less continually until his death. The nature of his diagnosis and treatment has remained unclear despite the large volume of written material dedicated to his life. In this article, the available medical and radiographic records are analyzed in an effort to clarify his diagnosis and treatment course, as well as to examine the effects of the lumbar spine disease on his life and political career.

Military Service and First Surgical Intervention

Kennedy's earliest complaints of low-back pain occurred during his undergraduate years at Harvard, which dates its onset to 1939 or 1940, when he was twenty-one or twenty-two years old. A frequently cited account of a football-related injury stems from the recollections of his mother, Rose Kennedy^3,6-8. Contrary to that account, a clinical note from the Charleston Naval Hospital, dated April 13, 1942¹², records Kennedy's description to his physician of the onset of back and buttock pain following a tennis match in the latter part of 1940. Whatever their initial cause, his low-back symptoms appear to date to this period.

Kennedy was initially declined as a volunteer to both the United States Army and Navy because of his low-back issues^6,7,13,14. He apparently undertook a personal rehabilitation and exercise program and was judged to be physically qualified for duty on the basis of a medical examination performed on August 5, 1941, gaining entrance to the Navy as an intelligence officer in 1942.

On May 18, 1942, Kennedy underwent an assessment at the office of Dr. Marius Smith-Petersen (Fig. 1)¹². By this time, the option of fusion surgery of the spine and/or sacroiliac joint had already been discussed during assessments at both the Mayo Clinic and the Lahey Clinic in Boston^6,7. Dr. Smith-Petersen felt that Kennedy's pain pattern did not indicate a neurological origin, as he stated, "I don't think this is a disc since the pain complained of does not even remotely resemble a disc,—no interference with reflexes, nothing pointing to a spinal condition." He requested an assessment of Ensign Kennedy by a naval neurosurgeon, Dr. James White, who concurred that Kennedy's pain pattern was not consistent with sciatica. A decision was made against surgical intervention¹².

Dissatisfied with his desk job in naval intelligence, Kennedy gained an assignment as the captain of patroltorpedo (PT) boat 109 in the Solomon Islands of the South Pacific, entering the PT boat training program on October 1, 1942^6,7,13. His crew members were aware of his continued back symptoms; Kennedy's accommodations to his condition included sleeping on a reinforced mattress while on the boat¹³.

In the early hours of August 2, 1943, PT 109 was rammed and sunk by the Japanese destroyer Amagiri. Over the subsequent five days, Kennedy rallied his men and personally performed numerous acts of physical exertion, including towing one badly injured man from the boat's wreckage over three miles of open ocean to a neighboring island. Ultimately, Kennedy and all crew members who survived the boat's sinking were rescued^3,6-8,13.

Whether Kennedy's back problems were due to the stresses of the rescue effort, the impact of the Japanese destroyer with PT 109, or simply the natural history of his underlying condition, they worsened following these events and ultimately became disabling. By this time, he was also suffering from other physical ailments, including colitis and malaria. Following his return to the United States, he was again evaluated for spinal surgery. Although still a member of the United States Navy, he was admitted, at his family's request and expense, to the New England Baptist Hospital in Boston. On June 23, 1944, he underwent a left-sided laminotomy of L4 and L5 with a discectomy at the L5-S1 interspace by Dr. James Poppen, a neurosurgeon with the Lahey Clinic^3,6-8,12.

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Fig. 1: Reproduction of an abbreviated clinic note from Kennedy's assessment by Dr. Marius Smith-Petersen on May 18, 1942. Kennedy was an ensign in the United States Navy and was considering fusion surgery for the treatment of persistent low-back and buttock pain. (Personal Papers of John F. Kennedy; Series 8, Naval Records Collection, Box 11A, John F. Kennedy Library, Boston, Massachusetts.)

Kennedy's recovery from this procedure appears to have been prolonged in comparison with that of a typical patient. While the New England Baptist Hospital medical records have not been released, Dr. Poppen's transfer note to the Chelsea Naval Hospital dated August 1, 1944, states: "I have had nine other patients in a series of over five hundred ruptured intravertebral discs with a similar experience [of severe postoperative muscle spasm].... I am indeed sorry that this had to happen with Lieutenant Kennedy."¹² (Fig. 2)

Kennedy was reevaluated on August 4, 1944, by Dr. James White, the same naval neurosurgeon who had seen him prior to his departure for the Solomon Islands. Dr. White questioned the indication for the surgery, noting that only an air spinogram, as opposed to a more sensitive Pantopaque (iophendylate) myelogram, had been done preoperatively¹². Dr. Poppen's transfer note does indeed state that "there, however, was very little protrusion of the ruptured cartilage" at the L5-S1 disc (Fig. 2). Kennedy himself joked in a letter to a girlfriend written during his hospitalization that "... in regard to the fascinating subject of my operation I... will confine myself to saying that I think the doc should have read just one more book before picking up the saw."^3,7

Anteroposterior and lateral radiographs of the lumbar spine dated December 14, 1944, show an essentially normal adult spine, with no evidence of degenerative disease, spondylolysis, or spondylolisthesis. This contradicts the reports by several prior authors that Kennedy had a "congenitally unstable spine."^8,10 As photography of the radiographs housed at the John F. Kennedy Library is not currently allowed, a medical illustration of the findings on a lateral radiograph of Kennedy's lumbar spine is shown in Figure 3.

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Fig. 2: Reproduction of an abbreviated transfer note from Dr. James Poppen following Kennedy's discectomy at the New England Baptist Hospital on June 23, 1944. (Personal Papers of John F. Kennedy; Series 8, Naval Records Collection, Box 11A, John F. Kennedy Library, Boston, Massachusetts.)

Early Political Career and Spinal Fusion Surgery

Kennedy received a medical discharge from the Navy on March 16, 1945. The reason for discharge was recorded as chronic colitis, rather than low-back injuries¹². Following his discharge from the Navy, Kennedy appears to have been physically and emotionally exhausted and uncertain of his future plans.

With the death in combat of his brother, Joseph Jr., and the encouragement of his father, Kennedy determined to run for Congress from the eleventh district of Massachusetts in 1946. An energetic political campaign schedule was mounted, despite Kennedy's continued difficulties with axial back pain; participants have described his frequent, steaming hot tub baths and use of a lumbar corset^1,4,6,7,15. Kennedy ultimately prevailed and was subsequently reelected to this congressional seat twice more before winning election as senator from Massachusetts in 1952.

Throughout this period, Kennedy's symptoms of low-back pain appear to have gradually and continually progressed. By the time of his first senate campaign, he often walked with crutches to unload his spine during public appearances^3,9,10,16. During his first senate term, the pain increased to a level that became increasingly unbearable. His personal secretary of twelve years, Evelyn Lincoln, relates in her memoirs that his mood during this period was negatively affected to such an extent that she considered seeking employment elsewhere¹⁷.

Radiographs from January 22, 1954, show that by that time the L5-S1 disc space had completely collapsed, with early osteophyte formation at the anterior lip of the disc space (Fig. 4). These radiographs show no evidence of osteoporosis or vertebral body fracture, in contrast to the findings described in a recent report¹. While Kennedy's maintenance on corticosteroid replacement would suggest the possibility of osteoporosis, such an effect is not present in his radiographic records.

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Fig. 3: Representation of the findings on a lateral radiograph made on December 14, 1944, following a left-sided L4 and L5 laminotomy with discectomy of the L5-S1 disc space. The findings on the radiographs made at that time were essentially normal. (Personal Papers of John F. Kennedy; Series 14, Medical Records Collection, Subseries 14.2. X-Rays, 1942-1963; Box 1ovz, John F. Kennedy Library, Boston, Massachusetts.)

As he continued to seek medical opinions for his condition, the option of spinal and sacroiliac joint fusion surgery was again discussed with Philip Wilson Sr., MD, at the Hospital for Special Surgery in New York City. Kennedy was thirty-seven years old and appears to have played an active role in the decision-making regarding his surgery. Because of the Addison disease, it was recognized that the procedure carried substantial risks, and the possibility of staging the sacroiliac and lumbar fusions was considered. Ultimately, however, the decision was made to proceed with a simultaneous posterior fusion of L5-S1 and the left sacroiliac joint on October 21, 1954^{1,3,6,9,12,16}.

The medical records of these assessments and hospitalizations are not available for review, although considerable information regarding his perioperative course is documented in several publications. As with his laminectomy in 1944, Kennedy's postoperative course did not go smoothly. Perhaps as a consequence of a postoperative urinary tract infection, he reportedly lapsed into unconsciousness and was administered the last rites of the Catholic church^3,6,8,10,16.

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Fig. 4: Representation of the findings on a lateral radiograph made on January 22, 1954, immediately prior to an L5-S1 posterior fusion and left sacroiliac fusion. Complete collapse and early osteophyte formation is present at the L5-S1 disc space. No instability, osteoporosis, or vertebral body collapse is present. (Personal Papers of John F. Kennedy; Series 14, Medical Records Collection, Subseries 14.2. X-Rays, 1942-1963; Box 4ovz, John F. Kennedy Library, Boston, Massachusetts.)

Kennedy's lumbosacral fusion was stabilized with an early form of spinal instrumentation, referred to as a Wilson plate^1,3,9,10. This was a Vitallium (cobalt-chromium) device that was curved to match the lordosis of the lumbar spine and was fixed to the spinous processes through transverse locking bolts^18-20. Postoperative radiographs dated November 12, 1955, show evidence of a left sacroiliac joint fusion with a posterior fusion of L5-S1 supplemented by placement of a Wilson plate and an L5 spinous process wire (Figs. 5-A and 5-B).

Following his postoperative discharge, he returned to his family's home in Palm Beach, Florida, to convalesce. Unfortunately, a wound infection developed, and he was readmitted to the Hospital for Special Surgery in February 1955 for instrumentation removal with wound irrigation and débridement. His wound apparently was not closed and was treated by repeated packing, with eventual healing by secondary intention^1,3,9. While a deep infection and high-dose steroids may well have led to a nonunion of the fusion sites, no dynamic radiographs are available to allow a determination of the success of the spinal fusion.

As an early example of elective surgery in patients with Addison disease, Kennedy's case history was included in a clinical series published in the Archives of Surgery in 1955²⁰. Despite the anonymity of the described patients, the congruence between the history of patient number 3 in that article and the timing of Senator John Kennedy's hospitalization as reported in the popular press was later noted by John Nichols²¹. Kennedy's identity as patient number 3 was ultimately confirmed by the lead author of the original article, J.A. Nicholas, MD, the first public verification by a physician that Kennedy in fact did suffer from Addison disease^11,22. An interesting sidelight is the relatively uncomplicated postoperative course described in the article for patient number 3, which contrasts with other biographical reports of Kennedy's struggles following the fusion procedure^1,3,6,8,9,16.

There is a persistent report within the spinal surgery community that Kennedy's surgical treatment included insertion of a Fernström ball, an early endoprosthetic disc replacement²³. On the basis of the available radiographs and medical records, this does not appear to have been the case. Furthermore, I could find no published source of this anecdote.

During his convalescence in Palm Beach, Kennedy participated in the preparation and writing of Profiles in Courage, a collection of historical vignettes regarding eight senators who followed policies requiring personal political sacrifice in order to uphold the public's greater interests²⁴. The book became a best-seller and won the Pulitzer Prize for Biography in 1957, raising Kennedy's visibility as a political figure of national stature.

At the time of the book's publication, there was speculation in the press that Ted Sorensen, Kennedy's speech-writer and assistant, had actually served as ghost author of significant portions of the book. While this was denied at the time both by Kennedy and Sorensen¹⁶, it has become the consensus of many historians that Sorensen did have substantial responsibility for portions of the book's content^1-3,8,10. Issues of authorship notwithstanding, Kennedy's considerable involvement in the book during his surgical rehabilitation is well documented and illustrates his lifelong habit of productive use of his personal time.

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Figs. 5-A and 5-B: Figs. 5-A and 5-B Representation of the findings on anteroposterior and lateral radiographs made in late 1954 following the surgical fusion. (Personal Papers of John F. Kennedy; Series 14, Medical Records Collection, Subseries 14.2. X-Rays, 1942-1963; Box 5ovz, John F. Kennedy Library, Boston, Massachusetts.) Fig. 5-A A Wilson plate crosses the L5-S1 interspace, is fixed to the spinous processes, and is supplemented by a wire at L5. Fig. 5-B A rectangular dowel graft is seen in the left sacroiliac joint.

Rehabilitation and the Presidency

Kennedy met Janet Travell, MD, during his recovery from the lumbar fusion. She was at that time a member of the faculty at Cornell University School of Medicine and a medical staff member at the New York Hospital. Dr. Travell's records of her early treatments are housed at the John F. Kennedy Library, and they comprise the only civilian medical records currently available there for review.

Following an office visit on May 26, 1955, Dr. Travell arranged for Kennedy to be admitted to the New York Hospital on June 17, 1955, for further assessment and initiation of a rehabilitation program. During this hospitalization, she gave him a rocking chair, which she felt was ergonomically favorable for his low back. This proved to be extremely popular with Kennedy and later received extensive coverage in the press during his presidency. He was ultimately discharged with a diagnosis of left sacroiliac and lumbar pain with continued muscle spasm following lumbar fusion.^9,12

Dr. Travell continued in the role of general physician and medical advisor to Kennedy during the years following the fusion operation. She directed his rehabilitation program and provided trigger-point injections of procaine when his symptoms were severe. She made herself available on a twenty-four-hour basis, traveling between her office in New York City and Washington to minister to her VIP patient's medical concerns⁹.

On December 6, 1957, Dr. Travell diagnosed Kennedy as having a recurrent abscess of the lumbar spine wound and arranged for another admission to the New York Hospital on that date. The abscess was irrigated and débrided by Dr. Preston Wade, and Staphylococcus aureus was cultured from the wound. This constituted Kennedy's fourth operation on his lumbar spine^9,12.

During the Democratic National Convention of 1960, Dr. Travell was called on to draft a statement in response to a disclosure that Kennedy suffered from Addison disease. Working with Eugene J. Cohen, MD, an endocrinologist, she produced a carefully worded statement denying the diagnosis of Addison disease on the basis that the original definition of the disease described tubercular destruction of the adrenal glands, which, of course, was not the etiology of Kennedy's adrenal insufficiency. Additional statements mentioned the fact that Kennedy's adrenal glands did function (although clearly not in the normal range) and the fact that he was not taking cortisone (although he was taking other corticosteroids). When Kennedy won the 1960 presidential election, in which he ran against Richard Nixon, he asked Dr. Travell to stay on as Personal Physician to the President, a role which she accepted⁹.

During the same time-period, Kennedy also sought the care of a less reputable physician, Max Jacobson, MD. Dr. Jacobson, sometimes referred to as "Dr. Feelgood," had a substantial list of celebrity clients, which included not only John F. Kennedy but also his wife Jacqueline. While Dr. Travell's trigger-point injections were limited to a local anesthetic, Dr. Jacobson apparently provided intramuscular injections of a cocktail of vitamins, hormones, and amphetamine among other ingredients^1,4.

Early in his presidency, in May 1961, Kennedy's low-back pain flared following a lumbar strain, which occurred during a visit to Canada. Again, there is some disagreement regarding the cause of the injury. While there is a commonly cited story regarding an inappropriately turned spadeful of earth during a tree-planting ceremony^{1,4,8,10,16,25,26}, Dr. Travell's medical records from the White House make reference to a golf outing over rough terrain¹².

Whatever the immediate cause, Kennedy returned from Canada again using crutches to walk comfortably. The timing of this incident unfortunately corresponded with Kennedy's planned first summit meeting with Nikita Khruschev. While the trip to Paris, Vienna, and London was not postponed, Kennedy made arrangements to have Dr. Travell and Dr. Jacobson travel to Europe as part of the presidential entourage and he was apparently administered one of Dr. Jacobson's injections prior to meeting with Mr. Khruschev^4,10,27.

Ultimately, concerns regarding Kennedy's reliance on passive treatments such as injections were raised by a second White House physician, Rear Admiral George Burkley, MD. These concerns led to a change in Dr. Travell's role as Personal Physician to the President. While she retained this position in title, the oversight of the medical care of the president was largely taken over by Admiral Burkley. In addition, Dr. Jacobson was blocked from further contact with Kennedy with the assistance of his brother, Robert F. Kennedy^1,4,10. Despite Kennedy's extensive reliance on several types and sources of injections, there is no direct evidence that he routinely used either oral or injectable narcotics for pain control.

On the advice of Admiral Burkley, another orthopaedic surgeon, Dr. Hans Kraus of New York City, was consulted to help manage Kennedy's low-back problems. Dr. Kraus did not recommend further consideration of surgery but started Kennedy on a regimen of aerobics, strengthening, and flexibility exercises and reduced Kennedy's reliance on procaine injections. The exercises were carried out in the area of the White House swimming pool, which was refurbished at the expense of Kennedy's father in order to allow privacy. This shift toward active rehabilitation starting in October 1961 did apparently give Kennedy some pain relief, and he maintained the exercise regimen throughout the remainder of his life^1,4,12,16,25.

Despite his persistent and severe low-back pain, Kennedy appears to have made relatively few concessions to the lumbar spine condition. His complaints to his friends and coworkers seem to have been limited mostly to self-deprecating humor and jokes at the expense of his physicians' lack of success. While he did limit activities such as golf and lifting his children when his back was especially troublesome, he clearly maintained an exceedingly high level of physical and intellectual activity despite his incapacity^{1,4,5,9,15,16,25,26,28,29}.

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Fig. 6: The likely arrangement of a double hipspica elastic wrap over a lumbar corset worn by Kennedy during the summer and fall of 1963, as well as on the day of his assassination.

Assassination

In addition to the surgical and physical medicine approaches described above, Kennedy also wore a lumbar corset on a regular basis. He apparently began wearing such a device as a young man and continued to use one throughout much of his adult life^1,8,16,25. Sometime in the summer of 1963, he began supplementing this corset with an elastic wrap, applied in a double hip-spica fashion (Fig. 6). The reason for this added bandage, as documented in the White House medical records of Dr. Kraus, was a hip flexor strain, or groin pull injury^2,12.

There has long been conjecture that his lumbar brace may have contributed to Kennedy's persistent upright posture in the presidential limousine in Dallas on the day of his assassination^1,2,8,30. There is documentation from the Parkland Memorial Hospital physicians who cared for Kennedy on the day of his assassination that both the corset and the elastic wrap were in place; the elastic wrap was, in fact, cut off the president during the resuscitation effort in order to access the femoral vessels^2,30-32. The corset and cut pieces of elastic wrap are currently housed at the National Archives in College Park, Maryland, as part of the President John F. Kennedy Assassination Collection (Fig. 7).

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Fig. 7: Photograph of the corset and elastic wrap worn by Kennedy on the day of his assassination. The elastic wrap was cut off by the physicians treating Kennedy at Parkland Memorial Hospital in order to establish intravenous access for fluid resuscitation. Its total length is 12 ft (3.7 m). (FBI Exhibit C35, President John F. Kennedy Assassination Collection, National Archives, College Park, Maryland.)

The 8-mm film of the assassination made by Abraham Zapruder allows precise timing of the gunshots that resulted in President Kennedy's death³³. On that film, the first shot occurs at approximately frame 210, while the fatal head wound is recorded at frame 313. Given a film speed of eighteen frames per second, President Kennedy would have had 5.7 seconds in which to have taken evasive action following the first shot in order to avoid the path of additional bullets.

The Zapruder film also shows that Texas Governor John Connally, who was seated immediately in front of Kennedy and suffered several nonfatal bullet wounds, did indeed fall to his left side within this time frame. Following his injury, which occurred after President Kennedy's injury by the first bullet³⁴, Governor Connally fell to his left and was out of the path of additional bullets by the time of the impact of the third and fatal bullet³³. Thus, there would presumably have been sufficient time for Kennedy to have made similar movements.

An understanding of the immobility produced by the bracing arrangement worn by President Kennedy on the day of his assassination makes clear that this would not have restricted him to such an extent that he could not have gotten out of harm's way. Even with the tightly applied elastic wraps, Kennedy would have retained sufficient flexibility through his hips to drop to his left side. The reasons for his persistent upright posture must rest elsewhere. As the first bullet passed through his trachea^31,32, it is possible that it triggered laryngospasm, which is supported by his grasping motions toward his neck demonstrated on the Zapruder film³³. Such effects may well have prevented him from the mental and physical focus that volitional movement out of the path of additional bullets would have required.

Conclusions

John F. Kennedy suffered from low-back pain throughout most of his adult life. Previous reports of congenital instability, osteoporosis, and spinal fracture are not supported by a review of existing medical and radiographic records. Instead, the underlying diagnosis appears to have been degenerative disease of the lumbar spine.

Having undergone several surgical procedures on the lumbar spine without substantial relief of his symptoms, he is an early example of failed spine surgery syndrome. His continued, exceedingly high level of activity despite his considerable discomfort not only illustrates his personal determination but also serves as a notable demonstration that such patients can maintain a substantial functional status despite their physical incapacity.

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Topics

medical record, device ; libraries ; lumbar vertebra ; pain ; spinal fusion ; rehabilitation ; lower back ; spinal procedure

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Robert A. Hart; Failed Spine Surgery Syndrome in the Life and Career of John Fitzgerald Kennedy. The Journal of Bone & Joint Surgery. 2006 May;88(5):1141-1148.

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