Seizing

Up – Progression markers of Ankylosing

Spondylitis (AS) on dry bone.
Maria Leroi₁ , Jennifer Sizemore₂, Magdalena Auron₃, Winsome Lee₄, Xenia-Paula Kyriakou₅,
1. Independent researcher, maria_leroi@hotmail.com; 2. California State University, Chico, USA; 3. Independent researcher, magdalena.auron@gmail.com; 4. Forensic Science Institute, University of Leicester, Odyssey Fieldschool
winsome2989@me.com; 5. Department of Bioarchaeology, University of Warsaw, xeniapaula.kyriakou@gmail.com Research Initiative

WHAT IS AS AND HOW IS IT DIAGNOSED?

Ankylosing Spondylitis (AS) is a chronic inflammatory disease that primarily affects the sacro-illiac joint (SIJ) and the axial skeleton, but also leads to development of syndesmophytes, and
progressive skeletal hyperostosis that leads to the ankyloses of vertebral bodies.
Both paleopathological and clinical literature agree on the SIJ involvement and fusion of the axial skeleton as primary criteria for the diagnosis of AS. Paleopathological literature describes the
process of the fusion as being from the SIJ upwards with costovertebral joints also being affected. Clinical diagnosis is based on assessment on chronic back stiffness not relieved by rest,
exercise or NSAIDs, uveitis, in conjunction with radiographic imagery; a blood test for the presence of the HLA-B27 gene. The HLA-B27 gene has a strong correlation with AS.
CLINICAL CRITERIA -combination of various
PALEOPATHOLOGICAL CRITERIA modified criteria over the years (1961
criteria, 1984 Modified New York Criteria)

• Bi-lateral fusion of SIJ/SIJ involvement • Low back pain and stiffness for more than 3
• Joints commonly affected: SIJ, joints of the spine, months that improves with exercise and NSAIDs,
the costo-vert. joints but not relieved by rest
• Syndesmophytes • Inflammation of the spinal joints
• Mostly males before 30 (AS is characterised by an • Pain and stiffness in lumbar and thoracic region
early onset compared to DISH and other • Limited chest expansion
spondyloarthopathies) • HLA-B27 present (blood test)
• Onset at the SIJ and lumbar spine, progressing • Acute anterior uveitis
upwards to involve thoracic vert. and cervical in • Radiological criterion – sacroiliitis:
severe cases Grade ≥ 2 bilaterally Or grade ≥ 3 unilaterally
• No skip lesions
• Squaring of vert. bodies – bamboo spine (fusion of
syndesmophytes along the spine)

1of 3 clinical criteria And radiological criteria required Fig. 1. Paleopathological demonstrations of Ankylosing Spondylitis
for diagnosis of AS
Table 1. paleopathological criteria vs. clinical criteria for diagnosing AS RESULTS
§ 11 skeletons showed some degree of sacroiliitis.
AIMS and OBJECTIVES § 11 skeletons showed syndesmophytes activity. The majority were present in the
§ Analyse a significant sample size to observe changes on the SIJ and axial skeleton to
thoracic vertebrae, with one skeleton in the lumbar vertebra.
establish a set of skeletal markers to enable the diagnosis of AS in various stages.
§ 7 skeletons had at least 2 or more fused vertebrae that was not DISH.
§ Relate observed changes to paleopathological and clinical criteria.
§ Most of the skeletons have osteophyte activity in the lumbar region to differing
§ Understanding the changes in relation to AS and other associated conditions (differential
extents. This essentially forms one large skip lesion between the sacrum and the
diagnosis of similar osteological changes).
thoracic spine.
MATERIALS § DISH occurred in 12 skeletons, including the early stages in one skeleton.
§ With the cases of DISH recorded there is co-existence with some degree of AS
The Cyprus Research Reference Collection (CRRC) is a modern
associated syndesmophyte fusion.
population and it consists of approximately 2000 individuals (mostly
with known demographics), dating from 1975 to 2012.it is under the
curatorship of the Diocese and Odyssey Fieldschool. CRRC is
characterised by pristine skeletal preservation. Out of 2000 skeletons,
200 are catalogued. The skeletons used for the study came primarily
from the catalogued remains.

Table 5. Combined criteria applied to the sample

Table 2. the study sample

CONCLUSIONS
METHODS § It was not possible to determine a set of osteological markers for the early onset of AS
This study is based on macroscopic examination which was on dry bone.
conducted on all of the parts of the vertebral column (including § There is the potential to identify the early development of sacroiliitis before any
sacrum) and the are of SIJ. Criteria for this observation was fusion begins to occur in dry bone.
based on Seiper, et al. (2009). Three key aspects of the changes § This sample lacks the upward progression of fusion from the SIJ up through the
to the axial skeleton were observed: (1) types, (2) location(s), (3) lumbar vertebrae. The entire lumbar vertebral section is a large skip lesion with
degree of severity. Scoring of the severity was based on the syndesmophyte activity located in the thoracic vertebrae. This does not correspond to
mSASSS clinical criteria (Seiper, et al. 2009) on a scale of 0-3. paleopathology literature.
Unlike clinically, the same scale of scoring was used for both the Fig. 2. Study sample skeleton § There is a high level of co-existence of DISH (candlewax fusion along the right lateral
SIJ and the axial skeleton to avoid any confusion. aspect of thoracic vertebrae) and AS activity (bamboo spine, syndesmophytes, SIJ
0= unobservable/ no change fusion). There is a possibility that this could be a population specific trait or related to
other unspecified spondyloanthropy that affects this population.
1= mild § The study has highlighted a pattern of presence of syndesmophytes including
2= slight to moderate ‘bamboo spine’, co-existence with DISH, and marked osteophyte activity in the lumbar
vertebrae within the skeletons in the study sample.
3= serious to complete fusion

Table 3. the scoring system used for Fig. 3. mSASSS scoring system
the study

Observations were recorded for the presence and

severity of: syndesmophytes, osteophytes, lipping,
Diffuse Idiopathic Skeletal Hyperostosis (DISH), and
sacroiliitis.
Each type of activity was designated a colour code and Fig. 4. Sample observation forms

the location recorded on the forms presented on the Fig. 5. Paleopathological demonstrations of AS continued

right (Fig. 4).

Sacroiliitis Bony Growth Signature Skip Intervertebral Fusion on SIJ Fusion Spinal Fusion
FURTHER RESEARCH
Signs Lesion Space Fusion Hands and Feet Preferred Location § Establish the prevalence of co-existence of DISH and AS for this collection (CRRC).
Reactive Bilateral Non-marginal Posterior Fusion in feet Could be Posterior plane
§ Expand on the sample size to determine if the recorded pattern of AS activity is
Arthritis syndesmophytes
osteophytes
spinal fusion
Yes No
primarily, not
much involvement
complete population specific
with hands § Look into the possible effect the 1974 invasion had on the change of lifestyle for the
DISH Not associated Non-marginal ‘candle wax’ Right lateral (shift side Greek Cypriot population and the possible manifestation on the skeleton.
(no-inflammatory) syndesmophytes appearance, at on lumbar region)
osteophytes least 4 No No Not associated N/A § Apply the scoring system utilised by Jenifer Sizemore to the study sample and
vertebrae
affected evaluate its validity for this study sample.
Ankylosing Bilateral/Unilateral Syndesmophytes ‘bamboo Could be Anterior plane REFERENCES
Spondylitis spine’ with complete or Ortner DJ. 2003. Identification of Pathological Conditions in Human Skeletal Remains. San Diego Academic Press
intervertebral No Yes Not associated partial Seiper J., et al. 2009 (68). The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess
space fused spondyloarthritis. Ann Rheum Dis: 1-44
Waldron T. 2009. Paleopathology. Cambridge University Press
Table 4. Differential diagnosis criteria
ACKNOWLEDGEMENTS The authors are humble and grateful to Mr. Stamatis Petas and Father Elias Ella for facilitating access to the collection and the cemetery facility .