Although the correlations between magnetic resonance findings and long-term disease evolution range from poor to moderate, conventional precontrast and postcontrast magnetic resonance imaging provides sensitive and reliable measures to monitor multiple sclerosis activity over time. New pulse sequences with shorter acquisition times can be cost effective and reduce patients' discomfort. The application of other techniques that give more accurate estimates of disease burden and have higher pathological specificity might improve our understanding of multiple sclerosis evolution and provide new outcomes for monitoring clinical trials. Work is still needed to obtain optimal imaging of the spinal cord for multiple sclerosis diagnosis and monitoring.