The middle photo in Luigi Mangione’s header image on X, formerly known as Twitter, is an X-ray photo of a spine with four screws in it. The photo is sandwiched between an image on the left of a Pokémon called Breloom and a photo of Mangione hiking.

The “giant screws” were part of a surgery that one of Mangione’s friends and roommate, R.J. Martin, described as “heinous,” according to reporting in the Daily Beast.

Mangione was in debilitating back pain, Martin said. Despite being in pain, Mangione did not complain often and was apparently not on any pain medication, Martin said in an interview with the New York Times.

Mangione, Maryland native, has been charged with murder in New York in the shooting death of UnitedHealthcare CEO Brian Thompson.

Mangione lived at Surfbreak, a “co-living” space in Honolulu tailored to remote workers, for about six months. Martin, who is the founder of Surfbreak, met Mangione in 2022 when he interviewed him to be in one of the first cohorts of residents, which was $2,000 a month to live in. Martin told the NYT that Mangione was smart, accomplished and an upbeat engineer. He said Mangione’s “spine was kind of misaligned. He said his lower vertebrae were almost like a half-inch off, and I think it pinched a nerve.”

A misaligned vertebrae happens when the spine slips out of place or gradually moves out of alignment.

It can be painful when the movement puts pressure on nerves, and sometimes surgery is needed to fuse vertebrae and relieve the pain if medications, a back brace and physical therapy don’t help, according to the National Institutes of Health’s Institute of Arthritis and Musculoskeletal and Skin Diseases and several local hospital systems that treat the condition.

The X-ray picture on Mangione’s social media page appears to show screws along a neck and four long rods, which can be used to stabilize the spine in someone with the condition, called spondylolisthesis. Mangione referred to the condition on his Goodreads book review account and posted about surgery after an injury online, according to media reports.

Medical sites describe spondylolisthesis resulting from a birth defect, sudden injury and abnormal wear and tear on bones and cartilage from arthritis. In young people, sports is a common cause. Symptoms can be mild or severe and include pain, muscle tightness, burning or numbness, and stiffness. Sufferers can have trouble walking. Pain can recur.

Regardless, back pain is common and can be life altering and complex to treat. Pain lasting longer than 12 weeks is considered chronic. Studies show a link between people with ongoing back pain and mental health, particularly depression and anxiety, and substance use disorders — but rarely violence toward others.

Martin told CNN that Mangione told him he suffered a back injury and wanted to get stronger. “When he first came, he went on a surf lesson with other members and, unfortunately, just a basic surf lesson, he was in bed for about a week,” Martin said.

Martin said Mangione mentioned he had needed surgery earlier this year, which weighed on him. According to the NYT, the two friends talked about Mangione’s back pain and how it got in the way of his dating life.

“He knew that dating and being physically intimate with his back condition wasn’t possible,” Martin said. “I remember him telling me that, and my heart just breaks.”

After six months of living at Surfbreak, Mangione left to see his doctor on the East Coast, Martin said. He came back to Honolulu after and rented an apartment in the same neighborhood, the NYT reported. Then, Mangione left Hawaii in the summer of 2023 and Martin texted him in August asking how Mangione was doing after his back surgery. Mangione sent Martin scans of his spine after the back operation, Martin said.

“He sent me the X-rays,” Martin said to CNN. “It looked heinous, with just giant screws going into his spine.”

Martin told the NYT he asked how Mangione was feeling after seeing the photos.

“So, long story,” Mangione replied. “Will fill ya in in person. Back in Hawaii as soon as I can, I have to figure out some spine stuff here first.”

Martin told CNN that Mangione called him once after that exchange, but he didn’t pick up the phone. Martin said he texted Mangione a few times between March and June of 2024 to check in, but Mangione never replied.