Background and purpose:  Sporadic amyotrophic lateral sclerosis (sALS) is a disease with a focal clinical onset and contiguous spread. We examined patterns of disease spread following symptoms onset in sALS and whether the pattern of spread predicted survival. Methods:  Review of medical records (2003–2009) at London Ontario and Buenos Aires clinic cohorts retrieved 318 patients with sporadic sALS. According to patient self‐report, we determined eight spread patterns: rostro‐caudal, caudo‐rostral, crossed, circular, superior interposed, middle interposed, inferior interposed and isolated. The variables studied were as follows: age, gender, sALS phenotypes, time from onset to diagnosis and time and direction of the spreading to the first region. Survival from symptoms onset was analysed by Kaplan–Meier, Tarone‐Ware and Cox proportional hazards methods. Results:  The direction of first spread was horizontal in 33%, rostral to caudal in 32% and caudal to rostral in 21%, whereas spread to remote regions was observed in 14% of patients. Survival curves and 3‐ and 5‐year survival rates favoured patients with an isolated and caudo‐rostral pattern of spread compared to patients progressing to distant regions without involvement in the intervening region, or ‘superior and inferior interposed patterns’ (Tarone‐Ware P = 0.001, χ2 = 0.002 and χ2 = 0.006, respectively). Factors affecting survival were gender, time to diagnosis, flail arm phenotype and age at diagnosis. Conclusions:  We have provided evidence that not all spread in ALS is contiguous and that the nature of symptom progression influences survival. Patients with sALS with ‘interposed patterns’ had a worse prognosis, whereas patients with caudo‐rostral pattern fared better than the rest.