A potential history of back pain emerged on Tuesday as a point of interest in the UnitedHealthcare CEO murder case, based on accounts from two people who knew the suspect and details from his social media profiles.

Luigi Mangione is in custody in Pennsylvania and faces multiple charges there as well as murder charges in New York. While the gunman's motive remains unclear, police have said Brian Thompson, the head of one of the nation's largest health insurers, was deliberately targeted.

The case has drawn intense interest online, where sleuths have looked for answers as to how a 26-year-old from a prominent family who had attended an Ivy League college ended up an accused murderer.

Social media commentators said clues about back pain could explain both personal distress and difficulties obtaining insurance coverage for treatment.

Reuters could not determine whether Mangione had been diagnosed with a back condition or whether he sought, or received, treatment including surgery.

On social media, Mangione left a trail of clues, including a picture of an x-ray of a spinal surgery on his X profile and a review on Goodreads of a book called “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.”

In a 14-page handwritten document that Sky News identified as having been uploaded to his Google Drive account in 2021 and which has not been independently verified by Reuters, Mangione said he had a back injury known as an L5-S1 isthmic spondylolisthesis, in which one of the bones in the spine slips forward and presses on the vertebra below it.

Dr. Wellington Hsu, professor of orthopedic surgery at Northwestern University Feinberg School of Medicine, said about 6% of the population has this condition and most people don't even know it because it typically does not cause pain.

About 20% of people with this condition have symptoms, and of those, another 20% may need surgery.

Paul Piek, a 21-year-old software testing professional from Flensburg, Germany, met Mangione in March while watching a muay thai boxing fight in Ao Nang, Thailand.

The two and another friend of Piek's met up again in Krabi, Thailand on April 8 and roadtripped through Khao Sok and Bangkok, where they shared a hotel room for four nights and visited temples.

"He told us he did (muy thai) before his injury," said Piek.

Piek said Mangione told him he was interested in hiking when they met, with no further mention of his back injury. "It didn't seem like a problem," though he did opt out of one guided hike for an easier walk, saying he was ill.

Mangione said he was “between jobs” while in Thailand," said Piek, who described Mangione as a spontaneous travel companion, who enjoyed partying.

After traveling for another month alone, Mangione indicated in June that he was returning to the U.S., Piek said. In July, Piek stopped hearing from him.

BACK SURGERY

Mangione had left his previous employer, Truecar, a car buying platform with offices in California, in 2023, the company said.

A colleague he worked with there told Reuters he took leave during the middle of 2023 for about two months, a move the colleague's manager told him was due to back-related issues.

He also told the manager of Surfbreak, a co-living residence in Hawaii, that he had a back problem, and in August of 2023 sent him pictures of a back surgery, according to the New York Times.

Mangione's notes mention that his condition involved a stress fracture in the pars bone that connects the vertebrae to the spinal column.

Dr. Richard Nachwalter, a Morristown, N.J. orthopedic spine surgeon, said frequently a bone connecting the vertebra cracks from sports in adolescence, fails to heal and changes the mechanics of the spine, causing the vertebrae to slip forward over time.

"As it slides forward, the disc degenerates, and either you get back pain, and if it slides and pulls on a nerve, you'll get leg pain," he said of spondylolisthesis.

Mangione's profile on X includes an x-ray of a person who has had an L5-S1 spinal operation in which two vertebra are surgically fused together. The surgery has an overall success rate of 80%, according to the National Institutes of Health.

In general, a spinal fusion surgery in a young person "should be a very predictable operation," Nachwalter said.

"You should be able to live your regular life, go back and play sports, play golf," he said.