Hematogenous vertebral osteomyelitis is an increasingly important consideration in the differential diagnosis of patients presenting with back pain even in the absence of fever. The incidence of this disease is increasing and physicians must maintain a high index of suspicion to make a prompt diagnosis. In patients with progressive neurologic deficits, urgent diagnosis is imperative, as the window for necessary surgical intervention is narrow. Magnetic resonance imaging is the preferred radiologic modality because of its sensitivity. Bone biopsy is the gold standard for diagnosis and is usually performed percutaneously using CT-guidance. Antimicrobial therapy of at least six weeks in duration is recommended and should be tailored to pathogens recovered from bone biopsy culture. With improved diagnostic techniques and prompt management, adverse outcomes associated with a delay in diagnosis can be avoided.