Significant symptoms of spinal injuries
The “significant symptoms” of the spinal injury cases are summarized in Table
1. In one case other information than the signs and symptoms belonging to the diagnosis under study have been documented as well:
Case 33: "it is his fall head-downward which caused a vertebra to crush into its counterpart."
In no other case, the mechanism of injury has been described. In fact, this is the only case presenting information acquired from history taking or, more likely in this case, heteroanamnesis.
Although the symptom “stiffness of the neck” is documented in eleven cases (cases 3–8, 19, 20, 22 and 29), this symptom is reported in only one of the six cases with spinal injury. In the head injury cases, neck stiffness is attributed by the Egyptian physicians to what amounts, in our terms, meningismus from traumatic subarachnoid hemorrhage. The inability to rotate or flex the neck is described in seven cases (cases 4, 5, 7, 19, 29, 30 and 32), of which three cases deal with spinal injury. Whereas the diagnosis of a ‘cervical sprain with disc injury’ (case 30) is associated with the ability to rotate and flex the neck (although painful), the diagnoses “cervical stab wound, perforating a vertebra” and “cervical vertebral compression fracture” (cases 29 and 32, respectively) are related to the inability to do so.
In case 48, the only case dealing with a lumbar spinal injury, a unique type of physical examination is reported. The patient, presumably lying in supine position, is asked to extend and contract the legs. When the patients suffer from ‘a wrenching/sprain in the vertebral column of lower back with disc injury’ he will contract his leg immediately because of the resulting pain of vertebral origin. Interestingly, this is the only clinical symptom reported in this case. Although others hypothesized that this case represents the first description of non-traumatic low back pain [
20], this case most likely covers the diagnosis of a symptomatic traumatic lumbar intervertebral disc injury [
21,
22]. In fact, the maneuver described in case 48 can be considered as the clinical precursor of Lasegue’s sign [
23].
The papyrus includes two cases with spinal cord injury (cases 31 and 33). It is noteworthy that in these two cases significant symptoms related to injuries of the spinal column, e.g. stiffness of the neck and the ability to rotate and bend the neck, are not described at all. All of the reported signs and symptoms are related to the spinal cord injury. One symptom is documented in both cases: “unawareness of both the arms and legs”. The use of the term unawareness in this context is intriguing. It implicates that both motor and sensory functions are (completely) absent. After carefully reading case 31, we can conclude, however, that the accuracy of this description of neurological deficit leaves room to speculation. The following text, which is perhaps one of most interesting fragments of the entire papyrus, explains why:
Case 31: “…it is a dislocation of a vertebra of the back of his neck extending to his thoracic spine, that causes him to be unaware of both his arms and his legs. If however, the middle vertebra of the back of neck is dislocated, ejaculation arises from his penis.”
Based on the second sentence, we cannot do otherwise than to conclude this case concerns a spinal injury located at the lower part of the cervical spine resulting in a low cervical tetraplegia [
1,
3,
6]. From a modern perspective, we know that the motor and sensory tracts to the proximal parts of the upper limbs (myo- and dermatomes C5) would likely had have been intact in such a case. Therefore, it is plausible to assume that, in case 31, a certain ‘awareness’ of the upper extremities was preserved.
The papyrus contains the first known descriptions of autonomic dysfunction in spinal cord injury, including: priapism, urinary incontinence and abdominal distention (case 31). The bloodshot eyes (case 31), stupor and aphasia (case 33) are not related to the spinal cord injury as these signs are most likely the result of an inaccurately described closed head injury.
Categorization of spinal injuries
As mentioned, the papyrus excels by its topographic structure. The categorization of anatomical regions is also observed within the group of spinal injuries. Diagnoses of the cervical spine (cases 29–33) are clearly distinguished from diagnoses of the thoracic and/or lumbar spine (case 48). Furthermore, the cervical spinal injury cases can further be categorized in open (case 29) and closed (cases 30–33) wounds.
Each of the four closed cervical spinal injury cases concerns a unique diagnosis of the injured spinal column. An additional explanation on the diagnosis is provided by the writer in each case (see
Appendix). The modern diagnoses, as expressed in the case’s titles are
-
Case 30: cervical sprain with disc injury;
-
Case 31: cervical vertebral dislocation with spinal cord and head injury;
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Case 32: cervical vertebral compression fracture; and
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Case 33: cervical burst fracture with spinal cord injury and brain contusion.
Case 30 represents the least disabling type of spinal injury and has previously been interpreted as a whiplash injury [
24]. The case’s explanation includes a remarkably detailed description of the lost integrity of the non-synovial intervertebral joint, i.e. the intervertebral disc [
9,
21]. Case 31 concerns a more severe injury with separation of one vertebra from another. However, the extent and direction of the displacement injury remain speculative issues. In contrast, the explanation on the vertebral compression fracture accompanying case 32 includes a highly illustrative metaphor:
Case 32: “The inside of the back of his neck is like a foot sinking into cultivated soil; it is a compressing / collapsing downwards”.
It is hard to imagine that more than 3,500 years before the publication of Watson–Jones’s vertebral body fracture classification, the Egyptian physicians already distinguished vertebral body compression fractures from vertebral body burst fractures [
25]. The detailed description of the crushed fracture in case 33 suggests that post-mortem examinations were performed [
26,
27]. The same counts for the documented pathologic anatomic relation between the dislocated vertebra and spinal cord in case 31. Other Egyptologists, however, do not support the suggestion of postmortem examinations being performed in Egypt before the fourth century
b.c. [
21,
28]. Another question that remains is how the writer accurately determined the diagnoses of cases 30 and 32 in surviving subjects.
Although the signs and symptoms of spinal cord injuries reported in cases 31 and 33 are not entirely similar, the author did not clearly categorize the neurological deficits of these two cases into different entities. However, case 31 includes a very interesting remark:
Case 31: “…If however, the middle vertebra of the back of neck is dislocated, ejaculation arises from his penis.”
The writer describes a hypothetical alternative clinical presentation: a more cranial injury to the cervical spinal column would result in a different type of neurological sequelae, namely priapism and spermatorrhea. Although it is evident that the ancient Egypt physicians had great knowledge about human physiology and anatomy (see next paragraph), with the currently available knowledge we can say that the documented causal relation between the level of injury and mentioned neurological sequelae is an inaccurate one. Nonetheless, after reappraising the alternative scenario documented in case 31 we may conclude that, referring to the level of injury, the papyrus includes the oldest known categorization of SCI in history (!).
Causal relations in spinal injuries
Clearly, the author of the papyrus was a learned physician and anatomist. Besides the accurately documented diagnoses and their significant symptoms, the scroll also includes the first ever known reporting of causal relations in spinal injuries [
26]. Four causal relations are described in the spinal injury cases. In case 33, the mechanism of injury is related to the type of spinal column injury:
Case 33: “…his falling head downward, upon the vault of his head, forcibly drives one vertebra of the back of his neck into its neighbor.”
This sentence demonstrates that even in ancient times, physicians were aware of the effects of excessive axial loadings on the integrity of the vertebral bodies of the spinal column.
One of the most fascinating fragments of the papyrus concern the documentation of the (inexplicit) causal relation between the injury of the spinal column and spinal cord in cases 31 and 33:
Case 31“… it is a dislocation of a vertebra of the back of his neck extending to his thoracic spine, that causes him to be unaware of both his arms and his legs.”
Case 33: “…caused a vertebra to crush into its counterpart and you find he is unaware of both his arms and his legs because of it.”
These two causal descriptions illustrate that more than 3,500 years ago physicians already had substantial knowledge about human physiology. They knew that injuries to the spinal column had the potential to result in motor, sensory and functional deficits. Without doubt, it can be stated that the ancient Egyptian physicians were already aware of the vital functions of the spinal cord.
The last causal relation documented in the spinal injury cases is the following:
Case 48: “… He has to contract it immediately because of the pain that it makes in the vertebral column of his back from which he suffers.”
In this case, the writer describes a rational explanation for the pain which is evoked by physical examination.