The clinical information and imaging data from 27 patients with hematogenous pyogenic vertebral osteomyelitis were reviewed. All patients had roentgenographic and magnetic resonance imaging examinations. Seventeen patients had computed tomograms; 17 had technetium Tc 99m medronate bone scans; and seven had gallium citrate Ga 67 scans. Magnetic resonance imaging, when used as a part of the initial radiologic evaluation, detected abnormalities consistent with osteomyelitis in all 27 patients. Magnetic resonance imaging also demonstrated paravertebral and/or epidural extension of infection in 14 patients, including seven patients who had neurologic signs of lower-extremity weakness. Roentgenograms, computed tomograms, technetium bone scans, and gallium scans had findings suggestive of the diagnosis in 48%, 65%, 71%, and 86% of the patients, respectively. We recommend magnetic resonance imaging as an important and perhaps critical imaging modality for detection of pyogenic vertebral osteomyelitis.