President John F. Kennedy was only 46 when he died in Dallas on November 22, 1963, yet he’d already undergone numerous operations and nonsurgical interventions for his debilitating back pain. Had he lived in our time, he likely would have had multiple low-back advanced-imaging exams too—probably more exercises in futility, given the extent of the damage.

The latter point is implied rather than spelled out in an intriguing hindsight consideration of JFK’s back published online July 11 in the Journal of Neurosurgery.

“The best-quality radiographs from the end of the president’s life are dated March 14, 1962, and show no evidence of the aforementioned [steroid-induced] compression fractures or coronal deformity or listhesis,” write T. Glenn Pait, MD, of the University of Arkansas and Justin Dowdy, MD, a neurosurgeon at Hot Springs Neurosurgery Clinic.

The x-rays do, however, “demonstrate neural foraminal narrowing at [the lumbosacral segment] L5–S1 and near-complete loss of lumbar lordosis, which was not evident on films from 18 years prior.”

The authors also explore the injuries that likely caused and perpetuated the pain—most notably on the football field and in the Pacific theater of World War II—and a previously proposed theory that Kennedy’s famous back brace may have contributed to his death.

“[T]he use of this tightly bound lumbar brace returned the president to an upright position after the potentially survivable first shot and back into Lee Harvey Oswald’s scope sight, allowing the second obviously fatal shot to the head,” they write. “Had the president not been wearing the augmented brace, he might have crumpled forward and remained out of Oswald’s line of fire.”

The journal has posted the paper in full for free, along with a brief accompanying editorial.