A comprehensive review of the denticulate ligaments: application to surgery of the craniocervical junction and spine.

The denticulate ligaments (DLs) are lateral pial extensions that tether the spinal cord to the dura mater and serve as important anatomical and surgical landmarks. Despite their long-standing description in anatomical literature, substantial controversy remains regarding their number, morphology, attachments, function, and clinical significance. The purpose of this review is to provide a comprehensive and updated synthesis of the gross anatomy, histology, development, variations, biomechanics, imaging characteristics, pathology, and surgical relevance of the DLs. Classical and contemporary cadaveric studies demonstrate marked regional differences in DL morphology, thickness, and dural attachment patterns, with distinct features at cervical, thoracic, and intracranial levels. Histological evidence confirms a collagenous core with region-specific fiber orientation and leptomeningeal continuity. Developmental and pathological studies further reveal variability, including absence, duplication, hypertrophy, and abnormal attachments, which may contribute to neurological symptoms or complicate surgical approaches. Biomechanical data suggest a limited but region-dependent role in spinal cord stabilization. Clinically, the DLs are critical landmarks in spinal and craniocervical surgery and may influence operative strategy in conditions such as tumors, Chiari malformations, tethered cord, and spasmodic torticollis. A precise understanding of DL anatomy is therefore essential for safe and effective neurosurgical practice.