Rationale. In recent years, significant advances have been made on the subject of MRI examination techniques, which have opened new avenues of research regarding the spinal involvement in amyotrophic lateral sclerosis (ALS).

Objective. Our objective was to compile and analyze the available literature data, concerning the MRI of the cervical spine in ALS, detailing the metrics and their significance in diagnosis and follow-up.

Methods and results. We have conducted an extensive search on the subject using literature data published over the last fifteen years, correlating it with our own experience.

In ALS, there is a permanent interest in developing new biomarkers that might be sensitive to spatial and temporal patterns of neurodegeneration, which will permit early diagnosis and hopefully lead to new therapeutic approaches. Both diffusion tensor imaging (DTI) and spinal cord morphometry (especially spinal atrophy) reflect different aspects of the disease and correlate with clinical deterioration. Newer approaches like inhomogeneous magnetization transfer (ihMTR) and multiparametric analysis seem to have better sensitivity, are more appropriate for follow-up, and lend themselves to prognostic conclusions.

Discussion. We conclude that MRI is a constantly expanding field, a unique non-invasive tool with immense potential in evaluating the in vivo evolution of the neurodegenerative ALS process, both structurally and functionally, with high hopes for the future.

Abbreviations: ALS – amyotrophic lateral sclerosis, UMN – upper motor neuron, LMN – lower motor neuron, EMG – electromyography, CST – cortico-spinal tract, FLAIR – fluid-attenuated inversion recovery, MND – motor neuron disease, DTI – Diffusion tensor imaging, FA – fractional anisotropy, MD – mean diffusivity, ihMTR – inhomogeneous magnetization transfer, fMRI – functional MRI