The optimal protocols and the role of contrast agents in spinal MR imaging are controversial. Although the diagnosis of many common spinal diseases can be reliably achieved by means of unenhanced images, contrast use is often necessary to improve lesion detection and differential diagnosis. The heterogeneity of the different spinal compartments and the wide variety of spinal pathology require tailored imaging strategies. Thus, the rules to achieve optimization of contrast protocols for MR imaging of the spine are frequently very different to those for brain imaging, and depend on the location and site of origin of the lesions in a specific spinal compartment, on the findings of unenhanced imaging, and on the concomitant use of fat-suppression techniques. Furthermore, in most cases, the small size of the examined structures requires a meticulous technique, and the administration of a contrast agent with high relaxivity, such as MultiHance, is advisable to enable the detection of tiny areas of contrast enhancement. The applications and clinical utility of post-contrast MR imaging are discussed with regard to different spinal diseases.