Li, David K.B.

The spinal cord plays a central role in the pathophysiology and clinical manifestations of multiple sclerosis (MS), yet remains under-studied compared with the brain. This review summarizes key insights from the 2025 North American Imaging in MS Spinal Cord Imaging Workshop, highlighting recent advances, ongoing challenges, and future opportunities in MS spinal cord imaging. We review pathological studies and outline the clinical relevance of spinal cord lesions and atrophy for diagnosis, prognosis, and disease monitoring, highlighting emerging biomarkers of progression independent of relapse activity. Correlations between magnetic resonance imaging, histopathology, and clinical outcomes support the validation and translational potential of advanced spinal cord imaging techniques. Finally, we discuss spinal cord–specific processing pipelines and reproducibility challenges. Collectively, these insights underscore the need to integrate advanced and quantitative spinal cord imaging into clinical trials, research studies, and—when feasible—clinical care, to fully capture the extent of MS pathology, and ultimately improve patient outcomes.

Abstract Purpose Ultra‐low field MRI scanners have the potential to improve health care delivery, both through improved access in areas where there are few MRI scanners and allowing more frequent monitoring of disease progression and treatment response. This may be particularly true in white matter disorders, including leukodystrophies and multiple sclerosis, in which frequent myelin‐sensitive imaging, such as magnetization transfer (MT) imaging, might improve clinical care and patient outcomes. Methods We implemented an on‐resonance approach to MT imaging on a commercial point‐of‐care 64 mT scanner using a non‐balanced steady‐state free precession sequence. Phantom and in vivo experiments were used to evaluate and optimize the sequence sensitivity and reproducibility, and to demonstrate in vivo performance and inter‐site reproducibility. Results From phantom experiments, T 1 and T 2 effects were determined to have a negligible effect on the differential MT weighting. MT ratio (MTR) values in white matter were 23.1 ± 1.0% from 10 healthy volunteers, with an average reproducibility coefficient of variation of 1.04%. Normal‐appearing white matter MTR values in a multiple sclerosis participant (21.5 ± 6.2%) were lower, but with a similar spread of values, compared to an age‐matched healthy volunteer (23.3 ± 6.2%). Conclusion An on‐resonance MT imaging approach was developed at 64 mT that can be performed in as little as 4 min. A semi‐quantitative myelin‐sensitive imaging biomarker at this field strength is available for assessing both myelination and demyelination.