Chapter 7
The Role of Imaging in Paleopathology
Chiara Villa1, Bruno Frohlich2,3 and Niels Lynnerup1
1
Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark, 2Department of Anthropology, Smithsonian Institution,
Washington, DC, United States, 3Department of Anthropology, Dartmouth College, Hanover, NH, United States
WHY IS MEDICAL IMAGING IMPORTANT?
Radiographic techniques, such as X-rays and computed
tomography (CT), are important diagnostic tools for
examining mummified and skeletal remains. They are
noninvasive and nondestructive approaches that facilitate
visualizing the internal structures of a bone or a mummy.
Radiological examinations can be complementary to the
macroscopic analyses of bones but are indispensable when
dealing with mummified remains. Radiography and CT
scanning of bones should be performed whenever possible,
both to help in the diagnosis of the disease and for a per-
manent documentation of the remains. Importantly, a per-
manent digital documentation of pathological samples can
be shared among experts and can be used to establish
pathology databases such as, “The IMPACT Radiological
Mummy Database of mummies” (Nelson and Wade, 2015)
or “Digitized diseases” (http://www.digitiseddiseases.org/).
This chapter provides a brief history and discusses the
basic technical principles and terminology regarding the
use of radiography in paleopathology. It also illustrates
how several diseases appear on X-rays and CT, including
taphonomic alterations, as distinguished from vital
changes. We also address certain borderline pathologic
conditions, which are often considered when compiling a
general health profile from a skeleton and which rely on
radiography. Finally, the chapter will also address the use
of certain other imaging modalities.
A BRIEF HISTORY OF RADIOLOGY IN
PALEOPATHOLOGY
The use of radiographic techniques in paleopathological
studies has a long history, starting soon after the discov-
ery of the X-rays in 1895 by the German physicist
Wilhelm Conrad Röntgen (Röntgen, 1972; Thomas and
Banerjee, 2013). Less than a year after the discovery of
X-rays, König performed the first radiographies on
Ortner’s Identification of Pathological Conditions in Human Skeletal Remains. DOI: https://doi.org/10.1016/B978-0-12-809738-0.00007-7
© 2019 Elsevier Inc. All rights reserved.
Egyptian mummies: a child and a cat (König, 1896).
Many other radiographic examinations were performed
in the following years, not only on mummies, but also
on dry bones and hominid fossils (for a review of the
early literature see Böni et al., 2004; Chhem, 2008).
Entire collections of mummies were radiographed
(Moodie, 1931; Harris and Weeks, 1973; Harris and
Wente, 1980; Dawson and Gray, 1968). Even though the
primary purpose of using X-rays was for documenting
collections (Chhem, 2008), several pathological changes
were described, including osteoarthritis, atheroma,
healed fractures, dental disease, and parasite-induced
changes (Brothwell and Sandison, 1967; Dawson and
Gray, 1968; Christensen, 1969; Harris and Weeks, 1973;
David, 1979; Harris and Wente, 1980; Bloomfield, 1985;
Lynnerup, 2007 and references therein). The first X-ray
studies with the aim of visualizing pathological changes
in humans for diagnostic purposes are attributed to
Eaton (1916), Means (1925), and Williams (1929).
In the early 1970s, the introduction of CT greatly
improved the capabilities of radiology (Hounsfield, 1973).
Once again, anthropologists and paleopathologists imme-
diately realized its importance for studying mummies and
skeletal remains. The first CT scan was performed on an
Egyptian mummy in 1979 (Harwood-Nash, 1979). Many
others soon followed; for a detailed review of the early
studies see Chhem (2008), Lynnerup and Ruhli (2015),
Cox (2015), and references therein. Today, X-rays and
CT scanning are routine research tools for studying mum-
mies, fossils, and bones.
BASIC PRINCIPLES AND TERMINOLOGY
This section is not intended to be exhaustive, but will intro-
duce the reader to basic principles and provide a glossary
for the most common terms (Table 7.1) associated with
radiography and CT scanning. For a full presentation,
please refer to, e.g., Bansal (2006), Buzug (2008),
169
170 Ortner’s Identification of Pathological Conditions in Human Skeletal Remains

TABLE 7.1 Glossary of Basic Radiology Terminology

Term Meaning
Artifact A discrepancy between the reconstructed values in an image and the true attenuation
coefficient of the object
Attenuation The reduction of X-ray intensities when passing through matter
Axial view In or along the axis (midline) of the body. A plane that is parallel to both the left right and
anterior posterior axes in the “patient-oriented” coordinate system
Beam (X-rays beam) The pack of primary X-rays emerging from the X-ray tube
Collimator Mechanical device for defining the shape of an X-ray beam
Contrast The contrast is defined as the difference in density (blackness) between various regions on a
radiograph
Contract resolution Ability to detect small differences in the attenuation coefficient of adjacent structures
Coronal view Coronal or frontal plane runs the length of the body and passes through it from side to side,
thereby dividing it into anterior and posterior portions
CT number An intensity scale for CT images. The unit for CT attenuation is called the Hounsfield unit (HU).
The numbers are set on a scale in which 1000 represents the attenuation of air and 0 is the
attenuation of water
Density The degree of darkening of a radiographic image: black areas (air spaces) have maximum
density, while white areas (bones, metal objects) have minimum density
Detector A physical instrument to measure the intensity of the incident X-rays
Exposition An image is underexposed, i.e., the object appears white or relatively featureless if insufficient
X-rays reach the film during the exposure; an image is overexposed, i.e., the object is not
distinguishable from the background if an elevated number of X-rays penetrate it during the
exposure
Field of view (FoV) Area of the scan
Helical (spiral) scan A CT scan mode in which the patient table travels continuously during the data acquisition
HU (Hounsfield unit) The unit for the CT number scale (see also CT number)
Pixel 2D picture element
Reconstruction algorithm or A mathematical process used to reconstruct the CT images from the measured attenuation
convolution kernel profiles
Radiolucent/radiolytic Material or structure that is easily penetrated by X-rays. Such an object appears dark on the
radiography or CT image
Radiopaque/radiodense Material or structure that absorbs and scatters X-rays. Such an object appears light on the
radiography or CT image
Resolution The ability to differentiate objects
Sagittal view The sagittal plane runs superiorly inferiorly along the dorsoventral axis.
Section parallel to the median plan of the body
Scanogram (scout view, tomogram, Survey image used for orientation in the CT scanning. A projection image similar to an X-ray
project radiograph) radiograph acquired with a stationary gantry and a continuously moving patient table
Slice thickness Refers to the resolution of the CT scan (axial plane)
Slice increment Refers to the movement of the table/scanner for scanning the next slice
Voxel 3D volume element, in a CT, is defined by the pixel and the slice thickness
Window (or windowing) The parameter that determines the interval of gray tones that are visualized
X-ray tube Source of X-rays. It consists of an anode and a cathode enclosed in a vacuum envelope

Fleckenstein and Tranum-Jensen (1993), Goldman (2008),
Hsieh (2009), Kalender (2011), Seibert (2004), and Seibert
and Boone (2005).
Radiographic techniques use X-rays to visualize the
internal structures of the object. X-rays are electromagnetic
waves able to penetrate materials. They interact with the
atoms of the material and can be absorbed or scattered.
The X-rays are said to be attenuated with a reduction in X-
ray intensity. Their absorption depends on the density,
thickness, and atomic number of the material. The X-rays
that pass through the examined object have a pattern of
intensity that reflects the absorption characteristics of the
object, and this pattern is recorded to form an image (i.e.,
radiography). The image will be darkest where the greatest
number of X-rays has reached the image detector (i.e.,
film, digital plate) and lightest where the greatest propor-
tion of the X-rays is absorbed by the sample. The materials
with a high density, such as compact bones and metal
objects, inhibit passage of the X-ray, i.e., they are radio-
dense or radiopaque and are visualized in white or light
gray. Less dense materials, e.g., soft tissues, allow a major
number of X-rays to pass, i.e., they are more radiolucent
and are visualized in black-gray. Empty space is rendered
in black.

An X-ray machine consists of: (1) a source of X-rays
(an X-ray tube) and (2) a medium to record the attenua-
tion of the X-rays and produce an image (i.e., an image
detector). The image detector is a film in conventional
radiography, or a digital plane in computed radiography
(CR) and digital radiography (DR). A radiograph is a 2D
visualization of attenuation variations in a 3D item.
The main factors that can influence the quality of radi-
ography are the tube voltage (kV) and the X-ray dose
(mAs), which determine the energy and number of X-
rays, respectively. The penetration power of X-rays is
determined by their energy. Low-energy X-rays are more
likely absorbed by the object and do not reach the image
detector, while high-energy X-rays easily pass through
material and are registered by the image detector. A good
image is obtained when most the details of an object are
visualized; thus a greater variation of X-rays should reach
the film, such that a greater difference of shades of gray
appears. Increasing the energy of X-rays (kV) is not
always the solution. Indeed, if all the high-energy X-rays
easily penetrate the object regardless of its composition,
the resulting image is completely homogeneous, and thus
the different structures cannot be distinguished. The num-
ber of X-rays (determined by mAs) reaching the film dur-
ing the exposure can also determine the quality of the
image. An image may be underexposed, i.e., the object
appears white or relatively featureless, if insufficient X-
rays reach the film during the exposure. Alternatively, an
image may be overexposed, i.e., the object is not distin-
guishable from the background, if an elevated number of
X-rays penetrate it during the exposure. Modern clinical
X-ray equipment (CR and DR) is now fully digitized, so
images can easily be manipulated such that brightness,
contrast, and sharpness can be improved. The relative
TABLE 7.2 Overview of the Most Typical Appearances of the Several Pathological Conditions as Observed by X-Rays
and CT Scanning
Inactive
Radiolytic Description Confined or
lesions circumscribed and
surrounded by a
sclerotic rim of bone
Examples Osteomyelitis (Fig. 7.1),
osteoblastoma
Radiodense Description Amorphous
lesions Example Calcification
The staging between “inactive,” “active,” and “aggressive” is best understood as a spectrum.
The Role of Imaging in Paleopathology Chapter | 7 171
position of the object, the X-ray source, and the image
detector can also have a great influence on the image, cre-
ating artifacts and distortions. The object should be
directly under the center of the X-ray beam, parallel and
close to the image detector (Seibert, 2004; Seibert and
Boone, 2005; Saab et al., 2008).
While a single image of the object is created using an
X-ray machine, hundreds of slices may be produced dur-
ing CT scanning. This is possible because the source of
the X-rays rotates continuously around the object that
moves through the CT scanner, and multiple image detec-
tors simultaneously acquire the X-ray projections (Hsieh,
2009; Kalender, 2011). Thus, the CT images are the result
of processing a large number of X-rays acquired from dif-
ferent angulations. The cross-sectional images (recon-
structed slices) are usually represented in a 512 3 512
pixel matrix, with each pixel representing the X-ray atten-
uation coefficient in a small volume (voxel) determined
by the underlying anatomy. The x and y (pixel dimen-
sions) of each slice in the transverse plane are determined
by the matrix size and the fields of view. The third voxel
dimension (z) is perpendicular to the transverse plane and
equals the slice thickness (Kalender, 2011).
Exposure parameters, such as the tube voltage (kV)
and the X-ray dose (mAs), can influence CT image qual-
ity, as well as slice thickness, slice increment, pitch, and
the reconstruction algorithm (see Table 7.2 for further
details). As a general guideline, we suggest that the sam-
ple should be scanned with the smallest thickness possi-
ble, and the pitch and slice increment values should be set
lower than the values used for the thickness to reduce
possible artifacts. For more in-depth technical considera-
tions, see Hsieh (2009), Kalender (2011), and Zollikofer
and Ponce de Leon (2005). In medical CT scanning, the
Active Aggressive
Confined or circumscribed No clear border, cortical expansion and
without a rim, meaning that destruction
the lesion is still growing
Benign tumors Malignant tumors, osteosarcoma,
aneurysmal bone cyst, infectious diseases
(Fig. 7.2), hematopoietic diseases
(Fig. 7.3)
New bone formation, which can be extraosseous and/or intraosseous
Osteosarcoma (Fig. 7.4), metastases of carcinoma of the prostrate,
fractures, osteochondroma (Fig. 7.5), cartilaginous exostoses (Fig. 7.6),
osteomyelitis (Fig. 7.1)
172 Ortner’s Identification of Pathological Conditions in Human Skeletal Remains

FIGURE 7.1 Osteomyelitis on a left femur: (A) photograph; (B) radiograph; (C) coronal CT scan; (D F) axial CT images (the 3D visualization on
the right indicates the slice position). Osteomyelitis has a complex development, and radiographically is characterized by both radiolytic and radio-
dense areas. In image (C), the sequestrum, highlighted by the lower arrows (white arrows in online version), is visualized as a regular radiolytic/radio-
lucent area, while the internal sclerosis, highlighted by the middle arrows (orange arrows in online version), is visualized as radiodense areas. Note
that the increased thickness of the cortical bone due to elevated periosteum production is well visible on the CT images, highlighted by the upper
arrows (light blue arrows in online version).

differences in X-ray attenuations of the tissues, i.e., the
difference in material density, can be measured using the
Hounsfield unit (HU) scale. The HU scale is calibrated
arbitrarily according to the attenuation of water (HU 0) and
air (HU 1000). Materials more radiopaque than water
result in correspondingly higher positive values of HU; soft
tissues have values around HU (20 100), while bones
have HU over 200, with higher values for compact bones.
X-ray and CT scanning examinations should ideally
be seen as complementary examinations. CT scanning has
three main advantages: (1) it overcomes the superimposi-
tion problem that prevents one from clearly seeing deep
areas or juxtaposed structures in plain radiography; (2) it
better visualizes the contrast between the different bones
and soft tissue; and (3) it generates 3D visualizations of
single structures. However, ordinary X-rays are probably
the most accessible technology for most anthropologists
and paleopathologists, especially considering that there
are portable X-ray machines that can be used in the field
(Conlogue et al., 2004; Nystrom et al., 2004).
FIGURE 7.2 Femur with pronounced destruction (arrows) of the diaphysis due to syphilis: (A) photograph; (B) radiograph; (C) coronal CT scan.

FIGURE 7.3 Multiple lytic lesions (arrows) of a skull probably caused by multiple myeloma (hematopoietic disorder): (A) photograph; (B) lateral
X-ray; (C) 3D visualization from CT scanning of the inside of the skull; (D) axial CT scan.
174 Ortner’s Identification of Pathological Conditions in Human Skeletal Remains

FIGURE 7.4 Destruction of the frontal bone (lytic area) with sunburst appearance in the frontal bone due to an osteosarcoma.

FIGURE 7.5 Osteochondroma on a rib: (A) photograph; (B) lateral X-ray; (C and D) transverse CT images of the rounded formations (the 3D visual-
ization on the right indicates the slice position). Note the nodular character of the mineralized portion of the tumor visualized as radiodense areas in
the X-ray and the CT images.

RADIOGRAPHIC APPEARANCE OF knowledge of the normal anatomy, anatomical variations,

PATHOLOGIC CONDITIONS and pathological conditions is essential. Abnormal bone
changes can be broadly categorized as abnormal bone
The evaluation of pathological changes in radiographic size, abnormal bone shape, abnormal bone formation,
images is not easy and requires experience. A thorough and abnormal bone destruction (see Chapter 5). The

FIGURE 7.6 Cartilaginous exostoses between the fibula and the tibia: (A) photograph; (B) radiograph; (C) coronal CT scan. The bone formation on
proximal epiphysis shows a marked bone sclerosis visualized as a radiodense area (white arrows).
radiographic findings of abnormal bone size and shape
often correspond well with the macroscopic changes.
Abnormal bone formation and bone destruction can be
visualized as whiter (radiodense) or darker (radiolytic)
areas. As emphasized for dry bones (Buikstra and
Ubelaker, 1994; Ortner, 2012), a clear and detailed
description of the radiographic images is fundamental.
Table 7.2 provides an overview of the most typical
appearances of the several pathological conditions as
observed by X-rays and CT scanning. Aside from the
basic diagnostic distinctions between bone remodeling
(bone growth and bone destruction resulting in radiopaque
and radiolytic areas, respectively, on X-ray and CT), it is
equally important, for dry bone macroscopic study, to
evaluate if these basic processes occur inside the bone
(intraosseous/intramedullar), on the bone surface (extra-
osseous), or a combination thereof, and whether a lesion
is superficial or involves more of the internal bone struc-
ture (see Chapters 4 and 5).
Most of the pathological conditions affecting dry bone
can be evaluated macroscopically. Radiography can
The Role of Imaging in Paleopathology Chapter | 7 175
provide further information, but the procedure is not
always essential for diagnosis. For example, osteoarthritis
can be recognized by the presence of osteophytes, poros-
ity of the joint surface, and eburnation; lingual hyperosto-
sis of the mandible (torus mandibularis) can also be
identified from a gross examination. Indeed, some patho-
logical lesions are only visible on direct inspection of dry
bones since the resolution of the radiography/CT images
is not adequate. This would pertain to slight periosteal
reactions on ribs, scorbutic changes (porous hypertrophic
bone), or cribra orbitalia. On the other hand, there are
pathologies such as osteoporosis, endosteal sclerosis, mid-
dle ear infection, and confirmation of suspected previous
(well-healed) fractures, which are invisible by gross
examination of the bone. Finally, there are cases where
both a gross evaluation and radiographic examination pro-
vide excellent complementary information, e.g., in cases
of lytic lesions, Paget’s disease (Mays, 2008), and tumors.
Modern radiological imaging constitutes an important
source of information (Ortner, 2005; Roberts and
Manchester, 2007; Mays, 2011). Comparing radiological
176 Ortner’s Identification of Pathological Conditions in Human Skeletal Remains
images of archeological specimens with those of living
patients can help the paleopathologist reach a diagnosis.
Indeed, paleopathologists can benefit from the large num-
ber of radiographic images available in the medical litera-
ture that present a great range of manifestations of
various diseases. An example of this is “radiopaedia”
(https://radiopaedia.org), a free resource with one of the
web’s largest collections of radiology cases and reference
articles. Additionally, paleopathology may contribute to
modern medicine, as not all lesions visible on dry bones
can be seen on radiological imaging, and notation of these
allows a more complete overview of the manifestation of
the disease (Ortner, 2005; Roberts and Manchester, 2007).
Mummies, Paleopathology, and Radiography
Mummies and bog bodies are unique samples for studying
ancient disease (refer to Chapter 22), as they allow for
examination of pathological conditions affecting soft tis-
sues and with a rapid onset and/or a short course
(Cockburn et al., 1998). Outside of performing a destruc-
tive autopsy, pathological conditions of the bones in mum-
mies can be investigated only through radiographic and
endoscopic imaging. Several pathological conditions have
been identified in mummies (refer to Chapter 22). Given
the continuing progress in medical imaging, mummies pre-
viously examined by X-rays may yield much revised and
additional information when CT scanning has been applied
(Villa et al., 2015; Zesch et al., 2016) or when newer gen-
erations of CT scan equipment is used (e.g., an embedded
arrow head in the shoulder region of a mummy was not
seen until a later, second, CT scan, capable of smaller slice
thickness, was used (Seiler et al., 2013)).
OTHER BONE CHANGES AND
RADIOGRAPHY
Aside from using radiography as a diagnostic tool for well-
defined diseases, as discussed in the previous section, radi-
ography may also be used to study changes in bone mor-
phology and internal architecture, which may reflect
changes related to diseases or perhaps be indicative of a
more general health (or growth) insult. For instance, a mac-
roscopic observation of bilateral, often distal diffuse perios-
titis of the lower limb bones may be indicative of a
nonspecific, chronic disease or its effects. Equally, there
are some observations that can only be observed radio-
graphically. In this section, we briefly focus on Harris lines
(HL), the estimation of body mass, and osteoporosis.
While perhaps debatable in terms of diagnostic precision
or evidence, these changes are nonetheless often reported
and interpreted in a diagnostic discussion.
Harris Lines
HL are bands of increased bone density that are seen as
opaque lines across the diaphysis and metaphysis of long
bones, parallel to the metaphyses (Harris, 1926, 1931a,b,
1933). They have been studied primarily in tibiae and fem-
ora, but they have also been observed in other long bones
such as the radii (see Primeau et al., 2018 and references
therein). Diverse terms have been used for HL: bone scars
(Dreizen et al., 1964), Park lines or Park Harris lines
(Lee and Mehlman, 2003), transverse lines (Mitchell,
1964; Garn and Schwager, 1967; Gindhart, 1969; Clark
and Mack, 1988; Egawa et al., 2001), growth recovery
lines or grow restart lines (Ecklund and Jaramillo, 2002;
Sajko et al., 2011), growth arrest lines (Harris, 1931a;
Blanco et al., 1974; Yao and Seeger, 1997; Khadilkar
et al., 1998), radiopaque transverse lines (Blanco et al.,
1974; Clarke, 1982; Hummert and Van Gerven, 1985;
Byers, 1991), growth recovery zones (Siffert and Katz,
1983), and opaque transverse lines (Khadilkar et al., 1998).
As will be noted, some of these terms reflect that radiogra-
phy is needed to observe HL.
HL arise from dissimilar reaction times between
osteoblasts and osteoclasts in times during temporary
cessation of growth, causing a band of increased bone
density, which becomes evident once the individual
resumes normal growth (refer to Chapter 4). Once the
epiphyses have fused to the diaphysis, HL can no longer
develop (Scheuer and Black, 2000). HL, caused by tem-
porary growth arrest, are attributed to a broad array of
etiologies such as malnutrition, metabolic diseases,
childhood diseases such as measles, mumps, and chicken
pox (Harris, 1931a; Hewitt et al., 1955; Park, 1964;
Gindhart, 1969), diabetes (Harris, 1931b), hypoparathy-
roidism (Rosen and Deshmukh, 1985), children with
psychosocial short stature (Khadilkar et al., 1998), juve-
nile chronic arthritis (Fiszman et al., 1981), consumption
of ethanol (Gonzalez-Reimers et al., 1998), or repeated
child abuse (Walker et al., 1997).
There is little research in the form of longitudinal
studies regarding the rate of disappearance and persis-
tence of HL. Dreizen et al. (1964) and Gindhart (1969)
found that some lines persisted, while others disappeared
during developing years. On the other hand, HL have
been confirmed in modern populations with known ages
above 50 years (Ameen et al., 2005) and from cadaveric
material with known ages above 60 years (Egawa et al.,
2001).
Plain radiography is the most commonly used method
to evaluate HL (Brickley and McKinley, 2004) (Fig. 7.7).
However, recent research suggests that CT scanning may
also be a valid tool (Primeau et al., 2016).

FIGURE 7.7 A radiographic of paired tibiae showing bilateral Harris
lines (arrows). Image courtesy of Dr. M.L. Jørkov, University of
Copenhagen.
Body Mass Calculations
Several methods for deducing body mass are based on
measuring the cortical cross-sectional area of the femur
or determining diameters and thickness of the cortical,
compact bone component of the femur, and other bones
(e.g., Ruff, 2000; Ruff and Hayes, 1983; Torchia and
Ruff, 1990; Lacoste Jeanson et al., 2017, and reference
therein). In a paleopathological context, body mass may
reflect growth stunting and may be used as ancillary
The Role of Imaging in Paleopathology Chapter | 7 177
information to include in diagnostic deliberations (e.g.,
Kacki et al., 2018). Body mass can also be used to
assess behavior-related changes due to activity.
Alternative noninvasive methods to evaluate the cross-
sectional area have been suggested based on the use of
radiographs (Runestad et al., 1993; Stock Jay, 2002;
O’Neill and Ruff, 2004).
Osteoporosis
Osteoporosis is a complex bone disorder of multifactor
etiology. It is a frequent metabolic bone disorder that
affects many postmenopausal women and elderly people of
both sexes. Diagnostic determination of osteoporosis in
past populations may, alongside specific underlying dis-
eases, supplement the “osteobiography” of a skeleton, as
osteoporosis may also reflect bone modifications related to
age, menopausal status, or lifestyle (see Curate, 2014 for a
review, and Chapter 16). Here we simply address the fact
that radiography, along with dual X-ray absorptiometry, is
probably the most commonly used technique to study oste-
oporosis in skeletons (Mays, 2008; Curate, 2014).
Radiogrammetry quantifies the cortical bone in tubular
bones and can be measured on a plain radiograph (usually
by computing the ratio between the total width of diaphy-
sis and the medullary cavity thickness, not unlike mea-
surement for calculating body mass) (Ives and Brickley,
2004). Singh et al. (1970) proposed the “Singh index” as
a score of the pattern of trabecular bone. For comprehen-
sive guidelines for radiogrammetric analysis, the reader
can refer to Meema and Meema (1987), Ives and Brickley
(2004), and Brickley and Agarwal (2003).
Radiogrammetry of the femur and the tibia has been
applied to evaluate age-related cortical bone loss in skele-
tal remains (Gonzalez-Reimers et al., 1998; Mays et al.,
1998). Also, many anthropological studies of cortical
bone has used the second metacarpal (e.g., Ekenman
et al., 1995; Lazenby, 1995; Mays, 2000, 2001, 2006;
Robb et al., 2010; Beauchesne and Agarwal, 2011). No
paleopathological radiographic studies appear to have
been conducted on trabecular bone loss in lumbar verte-
brae, which is diagnostic of osteoporosis in living
patients.
TAPHONOMIC ALTERATIONS
Taphonomic and diagenetic processes can influence imag-
ing and need to be considered carefully to avoid incorrect
diagnoses. For example, soil intrusion within bones can
be visualized as radiopaque areas and can be misinter-
preted as pathological lesions (Fig. 7.8) such as sclerotic
bone tumors (Mays, 2011).
178 Ortner’s Identification of Pathological Conditions in Human Skeletal Remains
(A) (B)
(C)
FIGURE 7.8 CT images of a left femur with radiopaque artifact result-
ing from soil embedded in the diaphysis (arrows): (A) sagittal view; (B)
coronal view; transverse view (C). Note that the cortical and the trabecu-
lar bone does not present any pathological change.
Postmortem alterations are usually more marked in
soft tissues than in bones (Ruhli and Boni, 2000; Ruhli
et al., 2004; Lynnerup, 2007; Lynnerup and Ruhli, 2015;
Sydler et al., 2015). Unfortunately, these values cannot be
applied directly to mummies or degraded dry bones.
Though morphologically well preserved, mummified tis-
sues display a different radio-opaque response (Ruhli
et al., 2004; Lynnerup, 2007). Consequently, 3D visuali-
zations created using the clinical ranges and the volume-
rendering technique are not always suitable for mummies,
especially if the mummy is wrapped or inside a coffin or
bundle. Bog bodies are an extreme case of postmortem
alteration: the diagenetic changes are so massive in these
mummies due to the acidic bog environment, that all
tissues, including bones and teeth, show very similar
values of HU (Villa and Lynnerup, 2012). In such cases,
a manual segmentation process, i.e., manual slice-by-slice
image editing, is necessary. The manual process of seg-
mentation (delineation and extraction) is often very time-
consuming (Lynnerup, 2008), but it can result in accurate
and precise 3D models. Software applications such as
Mimics (http://www.materialise.com/en/medical/software/
mimics), Amira (https://www.fei.com/software/amira-for-
life-sciences/), and 3D slicer (https://www.slicer.org/)
allow postprocessing of the 2D images (surface rendering
(SR)). In addition, the resulting 3D model obtained using
SR can be exported as “.stl” for further analysis, e.g., to
be 3D printed, and/or for virtual reconstruction. Three-
dimensional printed copies of bones can be used for
teaching or, as recently demonstrated, they can be manip-
ulated to overcome extensive diagenetic changes and help
in the final diagnosis (Lynnerup et al., 2016).
OTHER IMAGING MODALITIES
Microcomputed Tomography
Microcomputed tomography (micro-CT or µCT) is a CT
scanning technique forfeiting FoV for the highest possible
resolution. Objects can be scanned with a voxel resolution
of 1 µm. A micro-CT is equipped with similar compo-
nents to those present in a CT scanner but at a smaller
size; e.g., the X-ray tube typically has a window of
1 50 µm; the field of view is around 1 100 mm.
Different from CT scanning, a long acquisition time
(from 10 to 300 minutes) is necessary (Kalender, 2011).
Micro-CT has been used in bioarcheological contexts.
Some examples include the study of taphonomical
changes in bog body bones (Boel and Dalstra, 2007) and
the investigation of fossil teeth to evaluate antemortem
treatment of dental pathology (Oxilia et al., 2017).
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a nonionizing imag-
ing (not using X-rays) technique that provides detailed
information of organs and soft tissues. MRI uses properties
of the hydrogen atoms to “see” within a body. Hydrogen is
the most abundant atom in the body and is commonly
found in water and fat. The magnetic resonance (MR)
activate nuclei of the hydrogen, i.e., nuclei where the num-
ber of protons is not equal to the number of neutrons align
their axis of rotation to the magnetic field generated inside

the MR. When the field is turned off, the hydrogen atoms
gradually return to their normally random orientation. The
return process produces a radio signal that can be measured
by receivers in the scanner and rendered into an image
(Rinck, 2001; Talbot et al., 2011).
There are fewer hydrogen atoms in bones and in desic-
cated mummies, making MRI technique less efficient.
Several attempts have been made, unfortunately, without
success (Lewin and Notman, 1983; Notman et al., 1986;
Hunt and Hopper, 1996). The first visualization was pos-
sible only after invasive rehydration of the tissues
(Piepenbrink et al., 1986). Many studies have been con-
ducted, and MR images have been obtained without inva-
sive treatment of the sample (Ruhi et al., 2007;
Giovannetti et al., 2016). For a comprehensive review, the
readers can refer to Ruhli (2015) and Giovannetti et al.
(2016).
CONCLUSION
Radiographic technologies are outstanding diagnostic
tools for the paleopathologist. They are not invasive
and allow permanent documentation of the specimen.
Having access to radiography is a must for any paleo-
pathological laboratory, and serious consideration
should be given to bringing along portable X-ray
equipment in the field, if specimens cannot be removed
from the site.
Recently, concern has been raised about whether
X-rays may be detrimental to ancient DNA, and thus
whether X-raying or CT scaning should be avoided prior
to sampling for ancient DNA (Immel et al., 2016).
However, as far as we know, no studies have specifically
tested effects of radiation at the level of ordinary diagnos-
tic X-rays and CT scans on dry bone specimens. Wanek
et al. (2013) performed a theoretical study and concluded
that in mummified tissue, cell shrinkage caused by dehy-
dration probably decreased the impact of X-ray radiation
on mummified cells significantly, and that backscattered
electrons in cortical bone protected deeper lying ancient
cells from radiation damage. It should also be noted that
advances in digital X-raying have decreased radiation
levels, so that a normal X-ray of, e.g., a skull more or less
equals the background radiation level over approximately
5 years (refer to the Report of United Nations Scientific
Committee, 2010).
Finally, along with laser surface scanning, CT scanning
is an excellent source of 3D data, which may enable the
production of 3D print copies of specimens and lesions.
All these new modalities offer new and exciting ways for
presenting and sharing diagnostic deliberations and patho-
logical specimens, including for teaching purposes.
The Role of Imaging in Paleopathology Chapter | 7 179
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