Osteological evidence for spinal tuberculosis in medieval
skeletal series from Croatia
Željka Bedić, Department of archaeology, Croatian Academy of Sciences and Arts,
Zagreb, Croatia
Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis that is
most often transmitted through the respiratory system. The primary infection usually
starts in the lungs, after which it disseminates by the blood stream to other parts of the
body – the kidneys, brain and bones. The spine is the most common (in approximately
40% of cases) affected bone element (Aufderheide & Rodriguez-Martin, 1998). In
most cases of spinal tuberculosis an abscess erodes the anterior part of the vertebral
body and the intervertebral disc, ultimately resulting in destruction of the vertebral
body and the development of the characteristic gibbus of Pott’s disease. In preantibiotic times this deformity was present in nearly 60% of cases involving spinal
tuberculosis (Reinhart, 1932). This report presents four unambiguous cases of spinal
tuberculosis recovered from four medieval sites in Croatia.
Salvage excavations conducted in 1978 at the Stari Jankovci site in continental
Croatia revealed the presence of 95 Avaro – Slavic graves dated to the period between
the 7th and 8th centuries (Šmalcelj, 1981). One individual, a female aged between 20
to 30 years recovered from grave 37, exhibits clear osteological signs of tuberculosis
in the thoracic, and lumbar parts of the spine. Six thoracic vertebrae (T5-T10)
collapsed resulting in ankylosis and a sharply angled kyphosis (gibbus). The first
lumbar vertebra is also destroyed and fused with T12 and L2. The vertebra
immediately below (L3) exhibits increased height (it is 31 mm high compared to the
28 mm recorded in L4) that was most likely caused by compensatory growth
suggesting that the changes caused by tuberculosis in this part of the spine occurred in
childhood (Ortner, 2003).
The cemetery of Velim near Benkovac in the hinterland of the Adriatic coast
was excavated from 2004 – 2009 and revealed 121 graves. According to recovered
archaeological artefacts use of the cemetery was dated to the 8th and 9th centuries
(Jurić, 2004). The skeleton of a female aged between 50-60 years exhibits evidence of
spinal tuberculosis. The 8th thoracic vertebra collapsed resulting in ankylosis and
gibbus with T9 and T10. Another ankylosis is present in T6 and T7.
The third case is from the St. Anselmo cemetery in Nin on the eastern Adriatic coast
whose use was dated to the period between the 12th and 15th centuries (Kolega, 2001).
The skeleton of an adult female aged between 30-40 years recovered from grave 17
exhibits pathological changes characteristic for tuberculosis. The T7, T8 and T9
collapsed and fused resulting in a clear gibbus. This block is fused with one superior
(T6) and three inferior vertebrae (T10-12) giving a total of 7 fused vertebrae.
In 2002 and 2003 archaeological excavations in Stari grad on the island Pag recovered
116 skeletons from 14 communal tombs. On the basis of a variety of finds that
include earrings, belt-straps, a razor, rings, pendants, and a knife, the use of this
cemetery is dated to the period between 12th-14th century. The skeleton of a 30-40
years old female also has changes typical for spinal tuberculosis. Thoracic vertebrae
T4-T10 are completely destroyed resulting in a sharply angular kyphosis. In this case
11 thoracic vertebrae are fused together.
All of the described cases exhibited one or more collapsed vertebrae resulting in both
ankylosis and sharply angular kyphosis (gibbus) of the thoracic spine. In all four cases
the vertebral arches, including the joints and spinous processes are intact with
secondary bony ankylosis between them.
Differential diagnosis excluded osteomyelitis, vertebral compression fracture,
rheumatoid and septic arthritis, and other diseases that affect the spine. Osteomyelitis
of the spine usually manifests as a destructive lesion of just one vertebra and does not
end with ankylosis and kyphosis. In vertebral compression fractures with angular
deformity usually only one vertebra is involved, and the vertebral body is generally
destroyed to a lesser degree. If rheumatoid arthritis affects the spine then the most
marked changes occur in the diarthrodial joints of the cervical spine. Although septic
arthritis often terminates in bony ankylosis and is very similar to tuberculosis arthritis,
bone destruction is not that severe as in tuberculosis.
References:
Aufderheid AC., Rodrigez-Martin C. (1998). The Cambridge Encyclopedia of Human
Paleopathology. Cambridge: Cambridge University Press, pp. 121.
Reinhart M. (1932). Die Fälle von Spondylitis Tuberculosa in der Aargauischen
Heilstätte Barmelweid aus den Jahren 1912-1930. Beitrage zur Klinik der
Tuberkulose, 79: pp. 745-749.
Šmalcelj M. (1981). Stari Jankovci – Gatina (općina Vinkovci) – avaroslavenska
nekropola. Arheološki pregled, 22: pp. 142-143.
Ortner D. (2003). Identification of pathological conditions in human skeletal remains.
San Diego: Academic press.
Jurić R. (2004). Ranosrednjovjekovno groblje u Velimu kod Benkovca. Obavijesti
Hrvatskog arheološkog društva, 2: pp. 20.
Kolega M. (2001). Nin – arheološka istraživanja u sklopu župne crkve Sv. Asela
(Anselma). Obavijesti Hrvatskog arheološkog društva, 2: pp. 83-90.