Vertebral osteomyelitis is an unusual complication of pneumococcal infection. This report describes a patient who presented with back pain and lower extremity weakness after bacteremic pneumococcal pneumonia. Magnetic resonance imaging showed destruction of the L-4-L-5 vertebral bodies and thecal sac compression, and Streptococcus pneumoniae was isolated from an aspirate of the disk space. We found only 10 other cases of pneumococcal vertebral osteomyelitis in a review of the literature. In these 11 cases the presentations were usually subacute, and the onset of back pain was insidious. Elevated erythrocyte sedimentation rates were commonly noted. Computed tomography and magnetic resonance imaging were most helpful in delineating the extent of involvement in patients seen in the last decade. Successful treatment included surgery alone in 2 cases that occurred before the antibiotic era, surgery plus 6 weeks of antibiotic therapy in 1, and antibiotics alone for 4 weeks to 7 months in 5. Two patients seen in the preantibiotic era died.