HUMAN OSTEOLOGICAL METHODS

ADBOU, University of Southern Denmark Version

19. december 2011

CONTENTS
HEAD OF THE FORM Location/site number Grave number Context Coordinates Arm position Grave type Height Age Sex THE FORM Questionable features PRESERVATION Quantitative preservation Qualitative preservation SEX ESTIMATION Cranium Pelvis Postcranial skeleton AGE ESTIMATION Limbus acetabula Proximal tibia Femur linea aspera Femur fossa trochanteria Femur caput fovea EPIPHYSEAL FUSION DENTITION Dental developmental age Enamel hypoplasia Dental conditions CRANIAL MEASUREMENTS POSTCRANIAL MEASUREMENTS 3 3 3 3 4 4 4 4 5 5 5 5 5 6 6 6 7 7 7 10 11 11 11 12 12 13 15 15 17 18 20 22

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JOINT CHANGES Diffuse idiopathic skeletal hyperostosis (DISH) TRAUMATIC CHANGES LOG OTHER DESCRIPTIONS AND COMMENTS REFERENCES

23 24 25 27 27 28

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HEAD OF THE FORM

Location/site number It is crucial that the identification of the skeleton is unambiguous and correct. It is therefore important that both the location/site number and grave number are entered carefully and readable in their respective textboxes on the form. Several excavations/sites have been given different names over the course of time (for instance Tirup is the same location as Bygholm). As long as the site designation is unambiguous it is acceptable to use all synonyms, but it is most practical to use the same name on all registration forms from the same site. The site number is the excavating authoritys registration of the actual excavation. The site number is relevant to use where several excavations, dispersed in time, have taken place on the same site. Grave number The numbering of the graves and the skeletons in them is often not consistent. Many cemeteries were excavated during the course of several independent digs and thus have different systems of numbering for each dig. As a main rule, a skeleton found in a grave must get a number starting with G followed by a number (1, 2, etc.). Both in the field and in the anthropological lab, it is not uncommon to find remains from additional skeletons intermixed with the bones of the primary skeleton of the grave. If the additional bones can be assigned to the skeleton of a neighboring grave, they are transferred. If this is not the case, an independent registration of the additional bones is made. Context The grave numbers of additional skeletons are entered in the textbox context. These skeletons are given the same G-numbers as the primary skeleton in the grave they were found in. The only difference is that the number is followed by a letter. The letters A, B,.. are used for the skeletal parts that were identified as being different doing excavation and the letters X, Y, .. are used for the skeletal parts that were recognized as being from another person during examination in the lab. Such additional skeletons must always get their own skeletal registration form

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so at least one form exists for each recognized individual of a cemetery excavation. If it is logical and possible, other numbering systems should be converted to the G numbering system mentioned above. To be able to relate to the archaeological registrations, the original number is written on the registration form in brackets on the form. Coordinates In order to keep track of the position of finds doing an archaeological excavation a system of coordinates is put down in the excavation field. The space termed coordinates in the registration form refers to the points of the position of the grave in the system of coordinates. The two coordinates of the position of the cranium are entered on the form. The information about coordinates is found in the archaeological field form. Arm position Arm position is entered for the right and the left side respectively. The information about arm position is found in the archaeological field form. Grave type Six possible scores are used to describe the grave types. The information about grave type is found in the archaeological field form. /: No information about grave type 1: Grave without coffin 2: Wooden coffin grave - seen as traces of wood in situ, nails in situ or handles and mountings in situ in the grave. 3: A stone cist made of either natural stones or bricks. 4: A stone grave the grave is framed with either headstones, footstones or both. 5: Other grave types for instance ship burials. Height The length of the skeleton is measured in the grave (using definitions presented in Boldsen, 1984). The measurements are taken on skeletons found undisturbed in situ in the graves and the length of the skeleton is measured from the top of the skull to the distal point of the talus. It is important that all sources (the box, excavation forms, notes from the field osteologist, previous journals and field reports) are all examined both to maximize the sample size and to check for validity. The method

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of measuring the height as described above was not used on all excavations. If another method was used or if there are uncertainties about which method was used the measurement is given in brackets in the registration form. The height is given in centimeters. The information about height measured in the grave is found in the archaeological field form. Age In the textbox age in the head of the registration form the final subjective estimation of the age at death is given. Together with the space sex this is the last to be filled out in the form. Age is entered as an interval in years. Concerning children, it is possible to estimate the age within a narrow interval using the dentition and measurements of the long bones. The age is given as a decimal fraction of a year (for instance a child with an age at death of one and a half to two is written as 1.5 2). Concerning adults, an appropriate interval of years is given. The age is put down as the closest whole year and not to the next birthday (the interval 30 35 years is a span of 6 years from 30.00 35.99 years). Sex In the textbox sex in the head of the registration form the final subjective estimation of the sex of the individual is given. This is a score given according to a 5-point scale (see table 3) and is a joined assessment of the sex estimation scores of the cranium, pelvis and postcranial skeleton. Together with the textbox age this is the last to be filled out in the form.

THE FORM
Questionable features If a given trait cannot be registered a / is entered in the textbox on the form. This will usually occur if the bone is not preserved at all or if the bone is insufficiently preserved to make relevant observations. At least 25 % of a bone has to be preserved in order to score a given trait.

PRESERVATION
The preservation of the skeleton is given as a quantitative and a qualitative assessment (see table 1 and 2).

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Quantitative preservation The quantitative preservation describes how much of the skeleton is preserved. The scores 1, 2 and 3 are used. If less than 1/3 of the bones of the skeleton are preserved the score 1 is given. If approximately half of the bones are preserved the score 2 is given. If more than 2/3 of the bones are preserved the score 3 is given.

Table 1 Score 1 2 3

Quantitative preservation Description Maximum 1/3 of the bones is preserved Between 1/3 and 2/3 of the bones are preserved Minimum 2/3 of the bones are preserved

Qualitative preservation The qualitative preservation describes how well the bones of the skeleton are preserved. The erosion of the bone surface and the degree of fragmentation are considered. If the skeleton is poor preserved and more than 2/3 of the bones of the skeletons have a pronounced degree of erosion and fragmentation the score 1 is given. If the skeleton is intermediately preserved and 1/3 - 2/3 of the bones have a pronounced degree of erosion of surfaces and fragmentation the score 2 is given. If the skeleton is well preserved and less than 1/3 of the bones have a pronounced degree of erosion of surfaces and fragmentation the score 3 is given.

Table 2 Score 1 2 3

Qualitative preservation Description Poor Intermediate Well

SEX ESTIMATION
Sex is estimated according to the 5-point scale seen in table 3. In children the sexual characteristics have not developed and an estimation

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of sex is not possible to make. The sex is estimated only when os ilium, os ischii and os pubis are fused in acetabulum or when the synchondrosis spheno-occipitalis (S.S.O.) is fused (table 4) both features are fused by the age of approximately 16 years. When neither the pelvic nor the cranial bones are preserved the degree of epiphyseal fusion of the long bones is assessed - the degree of fusion then has to correspond to an age older than 16 years in order to estimate the sex. Note: Only one sex estimation score is given for the cranium, pelvis and postcranial skeleton separately.

Table 3 Score / 1 2 3 4 5

Sex estimation scores Description Sex cannot be estimated - the relevant skeletal parts are not preserved Distinctly male morphology Slightly male morphology The sex is indeterminable/children Slightly female morphology Distinctly female morphology

Cranium When estimating sex the following components of the cranium are assessed: the shape of Arcus superciliaris, the morphology of margo supraorbitalis, the size of processus mastoideus, the relief of linea nuchalis superior, angulus mandibula and the shape of protuberantia mentalis. The features are compared with the illustrations in ill. 1 and an overall sex estimation score for the cranium is given. Pelvis When estimating sex the following two components of the pelvis are assessed: incisura ischiadica major and angulus subpubicus. The features are compared with the illustrations in ill. 2 and an overall sex estimation score for the pelvis is given. Postcranial skeleton An overall sex estimation score is given based upon the robusticity and length of the postcranial skeleton.

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MALE

FEMALE

ill. 1. U. Freund

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MALE

FEMALE

ill. 2. U. Freund

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AGE ESTIMATION
The estimation of age at death has been one of the main topics within biological anthropological research for the past 150 years. The first systematic studies of cranial sutures took place in the 1860s and age estimation based upon dental attrition originates back to the late 19th century. A general development in society, where focus has been on expanding the implementation of technological features in all aspects of human life, has taken place throughout the past decades. This development is also reflected in the efforts of generating new knowledge about age at death estimated in skeletal material within the field of anthropology. Statistical based computer software has been developed (e.g. transition analysis) and other methods that use X-ray technology, microscopic analysis and chemical analysis have been introduced to improve the methods. In this way new methods of analyzing the age of death in skeletal material using scientific methods will be applied in the future. A new method named CEI (Calibrated Expert Inference) has been developed within the last couple of years. The method was introduced by a collaboration of researchers from the University of Southern Denmark, the Max Planck Institute of Demographic research in Rostock and Pennsylvania State University. The use of the method requires basic training in osteology and is based upon both observations made of skeletons from reference samples (skeletal material where age at death and sex is known) and statistical methods (logistic regression analysis and Bayes theorem). The following anatomical components can be used to estimate the age at death of individuals in European medieval and post-medieval periods. The indicated age marks the midpoint of the transition from a young to an old stage and the 95% confidence intervals.

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Limbus acetabula Young Old

The edge is rounded K: 30 [-11;73]. Photo: P. Tarp

The edge is sharp M: 28 [-7;60] Photo: P. Tarp

Proximal Tibia Young Old

The features are rounded K: 42 [-13;92] Photo: P. Tarp

The features are sharp M: 24 [-19;66] Photo: P. Tarp

Femur linea aspera Young Old

Linea aspera is rounded K: 30 [15;38] Photo: P. Tarp

Linea aspera is sharp and irregular M: 21 [-19;61] Photo: P. Tarp

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Femur fossa trochanteria Young Old

The area is smooth K: 54 [8;102] Photo: P. Tarp

One or more exostoses are seen M: 42 [2;82] Photo: P. Tarp

Femur caput fovea Young Old

Fovea is smooth K: 35 [8;63] Photo: P. Tarp

Fovea is pointed and irregular M: 33 [21;45] Photo: P. Tarp

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EPIPHYSEAL FUSION
The degree of epiphyseal fusion is scored according to the descriptions seen in tables 4 and 5. Epiphyseal fusion is registered for the proximal ends of the right and left humeri, claviculae and radii. Furthermore the fusion of the epiphyses of the right and left crista iliaca are registered. The ages of epiphyseal fusion of the bones in the skeleton are given in ill. 3.

Table 4 Score / 0 1 2 3

Epiphyseal fusion Description No information - the relevant bone is not preserved The epiphysis is loose The epiphysis is partly fused The epiphysis is fused but the epiphysis line is visible The line of the epiphysis is erased

Table 5 Score / 0 1 2

Spheno-occipitalis Synchondrosis (S.O.S. / S.S.O.) Description No information - the relevant bone is not preserved The synchondrosis is open The synchondrosis is partly fused The synchondrosis is fused

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ill. 3

Ill. Kuussmann 1988

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DENTITION
Dental developmental age In the textbox age the age that corresponds closest to the dental developmental stage is entered using the drawings in ill. 4 and ill. 5. It is the degree of mineralization that is important not the degree of dental eruption. The age is given as a decimal fraction of a year. A 6 months old child will get a scoring of 0.5 years. Likewise, a 4 months old child would give a score of 0.3 years. Only one decimal is used. For a fully developed set of teeth when the third molar has erupted and is in occlusion - the score 25+ (years) is given. In the textbox information the number of dental groups, used for age estimation is entered. A full set of deciduous teeth contributes six dental groups: Three groups in both the maxilla and the mandibular. The four incisors form one group, the two canines form one group and the four deciduous molars form one group. One group only has to be represented by a single tooth in order to get a positive score. The deciduous dental formula is given as follows: Deciduous dental formula: i 2/2 c 1/1 m 2/2 = 10 x 2 = 20 A full set of permanent teeth contributes eight dental groups: Four groups in both the maxilla and the mandibular. The four incisors form one group, the two canines form one group, the four premolars form one group and the six molars form one group. The dental formula for the permanent teeth dentition is given as follows: Permanent dental formula: i 2/2 c 1/1 pm 2/2 m 3/3 = 16 x 2 = 32 In cases where a child is in an age where both deciduous and permanent teeth are present the number of remaining deciduous groups and permanent erupted groups are counted separately. Afterwards the number of groups of the two types of teeth are added to get the final result to be entered in the information textbox.

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ill. 4

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ill. 5

Enamel Hypoplasia Enamel hypoplasia is irregularities in the dental enamel seen as an impressed band on the tooth. Hypoplasia is coursed by physiological disturbances and is formed while the tooth is developing. Enamel hypoplasia is only scored on permanent canines (see table 6). The upper left canine is preferred, but if it is missing the right canine is scored instead. Only hypoplasia visible to the naked eye is scored.

Table 6 Score / 0 1

Enamel hypoplasia on +3 Description No information - the tooth is not preserved Normal tooth without enamel hypoplasia One or more enamel hypoplasia

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We use the dental table of Haderup but others exist, see for instance Lynnerup et al. (2008) or Hillson (1996). Haderups dental table (Lynnerup et al 2008): right Permanent Deciduous
8 7 6 5 05 4 04 3 03 2 02

MAXILLA
1 01 + + 1 01 2 02 3 03 4 04 5 05

left
6 7 8

MANDIBULA Permanent Deciduous

8 7 6 5 05 4 04 3 03 2 02 1 01 1 01 2 02 3 03 4 04 5 05 6 7 8

Dental conditions In all categories only the 12 permanent teeth are scored. The tooth has to be in occlusion in order to be scored. Only teeth that with certainty can be identified are scored.

Table 7 Score / 0 1 2 3 4 5

The presence of the tooth Description No information - neither the tooth nor the relevant piece of jaw are preserved. Tooth found in the jaw Tooth has fallen out after death Tooth has fallen out before death Loose tooth tooth without the matching piece of jaw. 8. molar not formed The tooth is formed but not in occlusion

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Table 8 Score / 0 1 2 3 4 5 6 7 8

Dental attrition Description No information the tooth is insufficiently preserved Unworn tooth Attrition only in enamel Attrition has exposed the dentine in one cusp Attrition has exposed the dentine in two cusp Attrition has exposed the dentine in three cusp Attrition has exposed the dentine in four cusp Attrition has exposed the dentine so the dentine is visible interconnected in two or more cusps Attrition has removed the enamel of the mastical surface Attrition has removed the entire crown of the tooth

Table 9 Score / 0 1 2 3 4 5

Caries Description No information the tooth is insufficiently preserved Normal tooth without caries Initial caries seen as a dark shadow on the enamel Caries in the enamel Caries in the dentine but the pulp is not open The pulp is open due to caries Caries has destroyed the crown of the tooth

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Fistula/abscess is scored in the bone of the jaw. The tooth does not have to be present in order to score a fistle.

Table 10 score / 0 1

Fistula/abscess Description No information the relevant piece of jaw is not preserved Normal jaw, no fistulae One or more fistulae by the root of the tooth

CRANIAL MEASUREMENTS
The frontal bone (os frontalis) is a very robust bone this is the reason why this bone is used for morphometric analysis. When working with skeletons excavated from soil the state of preservation is an important factor. The frontal bone is frequently preserved even though the rest of the skull is destroyed by external factors such as pressure from the soil. Seven measurements are used that reflect the form, size and general appearance of the frontal bone: Six chords (measured with a sliding caliper) and one arch. Five of the measurements were described by Martin and Saller (1957) and the names of the measurements presented in that publication are given in brackets after the title of the measurements. The last two measurements 6 and 7 - were created to be able to describe the maximal curvature of the frontal bone and the size of arcus supraciliaris. 1. Outer biorbital width (M431) This measurement reflects the width of the upper face. It is measured between the most anterior points on the suture between os zygomaticum and os frontalis in both sides. This point is called the frontomalare temp. It is marked as number 1 on ill. 6. 2. Minimal frontal width (M9) This measurement reflects the minimum width of the frontal bone behind arcus superciliaris. It is marked as number 2 on ill. 6.

Anthropometric parameters such as M43 refer to the measurements defined by R. Martin in Martin and Saller (1957).

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3. Maximal frontal width (M10) This measurement reflects the maximum width of the frontal bone on sutura coronalis. It is marked as number 3 on ill. 6. 4. Frontal chord (M29) This measurement reflects the length of the frontal bone from nasion to bregma. It is marked as number 4 on ill. 7. 5. Frontal arch (M26) This measurement also reflects the length of the frontal bone but as an arch from nasion to bregma. The midpoint between nasion and bregma is marked with a pen. This dot defines the measurement point called mesomethopion. It is marked as number 5 on ill. 7. 6. Lower frontal chord The nasion mesomethopion chord. This measurement reflects the distance between nasion and mesomethopion. It is marked as number 6 on ill. 7. 7. Upper frontal chord The bregma mesomethopion chord. This measurement reflects the distance between mesomethopion and bregma. It is marked as number 7 on ill. 7.

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5 7 4 6

3 2 1

ill. 6. U. Freund

ill. 7. U. Freund

POSTCRANIAL MEASUREMENTS
Femur length The maximal length of both the right and left femora are measured on the measuring table. Length is entered millimeters with one decimal. In the case of children with unfused epiphyses the femur is measured without epiphyses. Where one epiphysis is fused, the other is held in place and measured thus with both epiphyses. If the unfused epiphysis is missing the score / is given as is the case if the entire bone is missing. See ill. 8. Femur epicondyle width The maximal width across both the right and the left femora epicondyles measured with a sliding caliper in millimeters with one decimal. In children the loose epiphyses are measured. See ill. 8. Humerus length (M1) The maximal length of both the right and the left humeri are measured on the measuring table. Length is entered in millimeters with one decimal. In the case of children with unfused epiphyses the humerus is

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measured without epiphyses. Where one epiphysis is fused, the other is held in place and measured thus with both epiphyses. If the unfused epiphysis is missing the score / is given as is the case if the entire bone is missing. See ill. 8. Humerus epicondyle width The maximal width across both the right and the left humeri epicondyles measured with a sliding caliper in millimeters with one decimal. In children the loose epiphyses are measured. See ill. 8.

ill. 8

JOINT CHANGES
In these textboxes the changes to the largest joints of the skeleton are entered. The joint rims of all bones of the joint of interest are scored as one entry. In the shoulder the humerus, scapula and clavicula are scored. In the ankle the tibia, fibula and talus are scored. In the knee the femur, tibia and patella are scored. In the pelvis the femur and acetabula are scored. At least half of the relevant bone has to be preserved in order to score it. Examples of joint changes are seen on ill. 9 and 10.

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Table 11 Score / 0 1

Joint changes Description The joint rim is not sufficiently preserved for it to be registered. Normal joint rim Lipping (osteophytosis): at least 10 mm long and 1 mm tall.

ill. 9. Photo: P. Tarp

ill. 10. Photo: P. Tarp

Diffuse idiopathic skeletal hyperostosis (DISH) DISH is a joint disease without known etiology but genetic heredity and diabetes are considered as possible causative agents. The paleopathological diagnosis requires an anterolateral fusion of at least four vertebrae. That is a fusion of the part of the vertebral column that is turned towards the inside of the body and towards the right. This is also known as dripping candle wax. The disease must not be mistaken for the condition pelvospondylite (Morbus Becterew) which is seen as symmetric and complete calcification of the longitudinal ligaments of the vertebral column. DISH does in most cases not cause any severe symptoms other than stiffness and unspecific pain to the back. Modern epidemiological studies show that DISH is found most frequently among Caucasoid in Europe and North America, that it is found primarily among persons in ages between 50 and 75 years and that it is more frequently found among males (65%) than females (35%). (Leden 2008; Verlaan et al. 2007) http://emedicine.medscape.com/article/388973-overview. Historical studies have tried to show a connection between DISH and monastic life as they assume a higher frequency of well nutriment and

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thus diabetes among monks than others in the surrounding society (see ex. Verlaan et al. 2007). Ill. 11 shows changes to the vertebral column related to DISH.

Table 12 Score / 0 1

DISH Description The vertebrae are not sufficiently preserved to be scored Normal vertebrae Minimum four vertebrae are fused

ill. 11. Photo: P. Tarp

TRAUMATIC CHANGES
The presence of trauma in four regions of the skeleton is scored: The cranium, the upper extremities, the lower extremities and a collective group of the rest of the skeleton (ribs and vertebral column). Trauma can be divided into two different types of fractures high impact and low impact fractures. The high impact fractures occur from sudden arising traumatic situations such as violent acts and accidents. The person is exposed to a trauma with such a high impact that the bone will get an immediate fracture. High impact fractures are seen on ill. 12 - 17. Low impact fractures are caused by continued pressure or pull on a bone throughout a long period of time with low energy. In time (up to years) the pressure will create small fractures to the bone for instance caused by an unfortunate working position. The low impact fractures are

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most often seen in the vertebral column and the pelvic bones but most other larger bones can be affected. Low impact fractures are seen on ill. 19 and 20. Open and unhealed fractures relate to trauma received around the time of death. However, it can be difficult to differentiate it from postmortem damage either arising in the soil or during excavation. When a sharp object strikes the fresh bone it leaves a shiny mark with sharp edges. When a blunt object strikes a cranium it leaves an impression on it often with secondary star-shaped fractures seen as beams away from the primary fracture site. When both unhealed and healed fractures are found in the same area the score 3 is given. ill. 12, ill. 13 and ill. 14 show examples of trauma arising due to sharp edged violence. Ill. 15 shows trauma arising due to a stroke by a blunt object. In ill. 16, ill. 17 and ill. 18 trauma arising presumably due to accidents is shown.

Table 13 Score / 0 1 2 3

Traumatic changes Description No information - the bones are not preserved Normal bones Open, unhealed fracture Healed fracture Both open, unhealed fracture and healed fracture

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ill. 12

ill. 13

ill. 14

ill. 15

ill. 16

ill. 17

ill. 18 Ill. 12-20: Photo: P. Tarp

ill. 19

ill. 20

LOG
Here the dates, who registered what etc. is entered. Initials on the person doing the registration are entered in the textbox termed signature.

OTHER DESCRIPTIONS AND COMMENTS

On the back of the form or on a separate form miscellaneous observations from the examination of the skeleton are noted. Both conditions related to human biology and other aspects should be noted. It is important to write down and describe findings of archaeological artifacts on or inside the skeleton. The finding of such objects is reported to the relevant archaeological authority and is turned in or discarded as soon as possible after an agreement has been made.

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REFERENCES
Boldsen, J. L., 1984. A Statistical Evaluation of the Basis for Predicting Stature from Length of Long Bones in European Populations. American Journal of Physical Anthropology , vol. 65: 305-311. Boldsen J. L. 2001. An epidemiological approach to the paleopathological diagnosis of leprosy. American Journal of Physical Anthropology 115: 380-387. Boldsen J. L. 2005a. Leprosy and mortality in the Medieval Danish village of Tirup. American Journal of Physical Anthropology 126: 159168.

Boldsen J. L, Freund U. H. 2006. Osteological leprosy Epidemiology and diagnosis. Scandinavian Journal of Forensic Science. Scandinavian Journal of Forensic Science 12: 54-59.

Boldsen J. L, Milner G. R., Konigsberg L. W., Wood J. W. 2002. Transition analysis: A new method for estimating age from skeletons. In: Hoppa R, Vaupel J, editor. Paleodemography: Age distributions from skeletal samples. Cambridge: Cambridge University Press: 73-106. Boldsen J. L, Mollerup L. 2006. Outside St. Jrgen: Leprosy in the medieval Danish city of Odense. American Journal of Physical Anthropology. 130: 344-351.

Christensen V. B., Boldsen J. L. 2001. blekassereglementet. Ugeskrift for Lger. 2001, 51: 7248-7249. Hillson. 1996. Dental Anthropology. Cambridge University Press Kuussmann, R. 1988. Anthropolgie. Handbuch der vergleichenden Biologie des Menschen. Band 1. Stuttgart

Lovejoy, C. O., Meindl, R. S., Mensforth, R. P. and Barton, T. J. 1985 Multifactorial determination of skeletal age at death: A method and

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blind tests of its accuracy. American Journal of Physical Anthropology 68:1-14.

Lynnerup, N., P. Bennike and E. Iregren. 2008. Biologisk Antropologi med human osteologi. Gyldendal. Mann et al. 1987. Reproducing our ancestors. Expedition: The University of Pennsylvania University Museum Magazine of Archaeology. 29: 29 Martin, R and K. Saller 1957. Lehrbuch der Anthropologie. Bd. 1. Stutgart Massler, Schour and Poncher 1941. McKern & Stewart 1957. Skeletal age changes in young American males. Massachusetts

Todd 1920. Age change in the pubic bone: I. the white male pubis. American journal of physical anthropology. 3: 467-470

Verlaan J. J., . F. C. Oner and . G. J. R. Maat, 2007. Diffuse idiopathic skeletal hyperostosis in ancient clergymen. European Spine Journal, vol.16: 1129-1135

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