A case of healing spinal infection from classical rome

Alessandro Canci(a), Lisa Nencioni(b), Simona Minozzi(c), Paola Catalano(b), Davide Caramella(d) and Gino Fornaciari(e)
a Department of History and Conservation of Cultural Heritage, University of Udine, Italy
bArchaeological Superintendence of Rome, Italy
c Unit of Anthropology, Dep. of Ethology, Ecology and Evolution, University of Pisa, Italy
dDivision of  Diagnostic and Interventional Radiology, eDivision of Paleopathology, Dep. Of  Oncology, Transplants and Advanced Technologies in Medicine, University of Pisa, Italy

Key words: healing spinal infection, tuberculosis, osteomyelitis, fungal infection, Classical Rome

Abstract
This paper describes a spinal infection in an adult male skeleton from Ist century AD necropolis in Rome. Pathological alterations of the lower thoracic vertebrae, including bone destruction and fusion, suggest either tuberculous spondylitis .The rarity of healing infections, as well as the non-diagnostic appearance of the lesions, have prompted this note.

Introduction
During osteological and palaeopathological examination of human remains from a cemetery of Rome suburbia, a skeleton showing considerable pathological changes of the spine was found. The human remains come from a necropolis located close to the Nomentana way, an important connection between the city of Rome and the rural settlements of the southern Sabina, in the Casale Capobianco locality (about 10 Km NE from the centre of the city).
The area along the Nomentana way, which crosses a wide part of the suburban Rome, has been investigated for several years by the Archaeological Superintendence of Rome. Many ancient settlements have been found, dated to the Middle Bronze Age, some of which lasted until the VI century AD. They were densely populated up to the Roman Republic Age, when they were substituted by broad rural villae and farms, surveying their agricultural products to Rome. Their economy, especially in the Imperial Age, was based on an intensive production model, which implied the exploitation of slaves (Consalvi, 2001).
The necropolis, which the skeletal sample object of this study comes from, is dated just to the Imperial Age, as many of the cemetery areas and monumental graves scattered along the Nomentana way. In particular, the site in which the necropolis is located shows traces of previous intensive agricultural exploitation and includes an area with a probable ritual function, this last one linked to the presence of a spring water. The first 4 burials belong to the I-II centuries AD, while during the II-III centuries AD the exploitation of the cemetery area reached the maximum with 19 graves. The last 4 burials are dated to the V-VI centuries AD, and since then the site has been abandoned due to the water infiltrations which made swampy the area (Brando, 2001).
The skeletal remains of 28 individuals from 26 simple ditches and one with a double inhumation were found: 8 males, 7 females and 13 non-determined. The age at death was low: the 44% of the population died before reaching the adult age, while most of the individuals (28%) died between 30-39 years old, and nobody over 50 years. The anthropological study of the skeletal remains indicates that about the 75% of the population shows traces of nutritional and disease stress indicators (enamel hypoplasia and porotic hyperostosis), as well as quite high frequencies of skeletal alterations linked to traumas or biomechanical stress. The whole set of data, although recorded on a low number of individuals, would suggest a quite low life quality and meagre health conditions, possibly referring to a small population of slaves or freedmen (Nencioni et al., 2001).

Description
The grave 32, object of this paper, belongs to the first chronological phase of the necropolis (Ist-IInd century AD; Brando, 2001). The body lied in a supine position in a simple ditch with the head oriented to West. The skeleton is complete and sufficiently well preserved (only the skull is fragmented). It belongs to a robust male aged 25-35 years old. The extimation of the age at death was based on the degree of sinostosys of ectocranial sutures and the tooth wear (Meindl and Lovejoy, 1985; Lovejoy, 1985), while the sex diagnosis was carried out on the base of morphologic features of the basin and the skull (Aksàdi and Nemeskéri, 1970; Ferembach et al., 1979). Stature was extimated to be 170,8 ± 2,99 cm (Trotter and Gleser, 1958, White formula), a higher value compared to the male average in the necropolis (166,6 cm).
The pathological alterations affect the lower thoracic spine from T6 to T12.  T6 and T9 vertebral bodies exhibit scalloping of the anterior ventral surface. A trapezoidal resorptive lesion is visible on the ventral part of T10. The bodies of T7 and T8 are fused with subsequent loss of the intervertebral disc space. Bone destruction, with large posterior cavitations, lined with a layer of compact bone, affects the two fused vertebral bodies. Due to post-mortem events, the vertebral arches were detached from the vertebral bodies affected by the pathological alterations. The retrieved spinal arches belong to the first six thoracic vertebrae. The transversal process of the ninth vertebral arch is missing, while no traces of T7 and T8 vertebral arches were found. None of the spinal arches shows signs of pathological alterations.
Spondylolysis at the pedicle affects L5 and bone spurs at the insertion of ligamentum flavum on T3 to T6 and L2 spinal arches are observable. In addition, the L5 spinous process appears remarkably flat, showing a cribrotic surface. Such alteration, scarcely described in the palaeopatology (Jansenns 1989, Ogilvie et al., 1998), is known as Baastrups’disease or “kissing spines”. It is caused by the repeated contact between the spinous processes of two adjacent vertebras, generally as a consequence of excessive lordosis (Resnick, 1995).
The X-ray and CT scan inspections, carried out on the spine in anatomical articulation, indicate the anterior gouge defect of T6 and T9 and the fusion of T7 and T8 vertebral bodies. The large posterior gouge defect and marginal osteosclerosis of a little remnant of T8 vertebral body are better discernible on CT scan three-dimensional reconstruction.
The other bones do not show pathological signs, with the exception of new bone apposition and bending at the first proximal of the left tibia, indicating oblique fracture and repair.

Discussion
As differential diagnosis in the case under study, pyogenic spondylitis, brucellosis, tumours and fungal infection should be considered (Thijn and Steensma, 1990).
Pyogenic osteomyelitis seems to be improbable, since sequestra is not present, paravertebral lesions are common and scanty new bone formation in the affected vertebrae is visible (Ortner and Putschar, 1985). In brucellar osteomyelitis the healing process may cause vertebral fusion, but the anterior and posterior scalloping of the vertebral bodies is not observed (Aufderheide and Rodriguez-Martin, 1998). Metastatic skeletal erosion can affect the spine but, in this case, lesions involve only the posterior elements of the vertebrae and usually affect the whole skeleton. Haematogenous spread of mycotic infections, like actinomycosis, can cause erosion of thoracic vertebral bodies, but usually pedicles and neural arches are not involved. Aspergillus infection, however, can affect the vertebral column miming tuberculous spondylitis (Resnick, 1995; Williams et al., 1999).
In conclusion, many elements (as the observed involvement of the cheap antibiotics online, the resorptive lesions on the vertebral bodies with scarce new bone formation, the absence of lesions on neural arches and on the transverse/spinous processes suggest the tuberculous spondylitis as the most probable diagnosis. In spite of that, aspergillosis infection cannot be fully excluded as a cause of the pathological conditions of the skeletal sample found in the grave 32 from the necropolis located in via Nomentana (Ortner and Bush, 1993; Ortner, 1999).
Spondylolysis and Baastrup’s features might be consequence of the abnormal biomechanical load subsequent to the vertebral lesions and kyphosis.
The focus of infection was probably in the vertebral bodies of T7 and T8, subsequently it affected intervertebral disc spaces, resulting in disc destruction and fusion of the vertebral bodies. The infection, spreading to the anterior ligaments caused anterior scalloping of T6 and T9 (aneurysmal syndrome, Thijn and Steensma, 1990) and the circular resorptive lesion of T10. The smooth-walled osseous contours of the lesions suggest a long-lasting illness followed by healing.
Reports of skeletal tuberculosis in the palaeopathological literature are quite rare. The most complete and detailed documentation comes from Roman Britain.
Stirland and Waldron (1990) describe two cases from the Ashton and Dorchester cemeteries (late 2nd to the middle 4th century AD) in which scalloping and collapse with marked kyphosis of spine were seen. Recently, Anderson (2001) reported a very clear case of Pott’s disease in an adult male from a cemetery (2nd – 4th century AD) at Towcester, where severe destruction and marked kyphosis involved the thoracic spine. Two cases, possibly related to tuberculosis, resulting in thoracic vertebral collapse and kyphosis and multiple joint involvement, were described by Cox (1989), from the site of Ancaster in Lincolnshire.
Tuberculous spondylitis is documented in Italy beginning since the Neolithic (Formicola et al., 1987; Canci et al., 1996) to the Bronze Age (Canci et al., 2001). At present, only other two cases of tuberculous spondylitis from Herculaneum during the Roman Age (1st century AD) have been described in literature (Capasso and Di Tota, 1999).
As reported by Pliny the Younger (Epistolae, V, 19, 6), tuberculosis seemed to be widespread in ancient Rome. The results obtained by the study of the main nutritional and health stress indicators (Nencioni et al., 2001) in the 28 skeletons found in the cemetery of Via Nomentana, reveal a rather poor quality of life in Rome suburbs, thus suggesting possible exposure to the risk of infections. At present, however, information about palaeoepidemiology of the infections in the ancient Rome is rare and further studies, more oriented toward palaeopathology, are needed in the future.

Aknowledgements
Research grant by MIUR cofin. 2001. We thank Prof. Adriano La Regina and Dr. Paola Di Manzano of the Archaeological Superintendence of Rome for entrusting this research.

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