Purpose: Vertebral osteomyelitis (VOM) is a rare disease. We sought to identify common organisms responsible for VOM and understand its clinical presentation in children. Methods: This was a retrospective study of children diagnosed and treated for VOM at our institute between 1995 and 2014. During this 20-year period, 27 children fit the inclusion criteria. An extensive search of hospital records for clinical parameters and etiologic agents was carried out. Results: The mean age was 11.8 years old in pyogenic VOM ( PVOM) and 3.5 years old in Tuberculous VOM (Tb VOM) ( P=0.02). The pathogens were as follows: 7 (35.9%) M. tuberculosis (Tb), 7 (35.9%) Methicillin-sensitive S. aureus (MSSA), 3 (11.1%) Methicillin-resistant S. aureus (MRSA), 2 (7.4%) E. coli, and 1 (3.7%) case of both S. typhi and S. pneumoniae. No organisms were identified in 6 (22.2%) cases. Of the 7 cases of Tb spondylitis, 6 (85.7%) were associated with pulmonary or milliary Tb. Of the 20 cases of PVOM, 70.0% did not have a predisposing condition for VOM, and the most common pathogens were MSSA (50.0%) and unknown organism (35.7%). Others included S. pneumoniae (7.1%) and MRSA (7.1%). Of the 6 cases where a predisposing condition existed, the pathogens were MRSA (33.3%), E. coli (33.3%), S. typhi (16.7%), and unknown organism (16.7%). The median interval from the onset of symptoms to the initial diagnosis was 35.5 (IQR 18.0-54.0) days in PVOM, versus 60.0 (IQR 28.0-150.0) days in Tb VOM ( P=0.09). Fever was present in 65.0% of the patients with PVOM versus 28.5% in Tb VOM ( P=0.09). Symptoms depicting VOM such as back pain, limping gait, or refusal to bear weight was seen in 85.0%, 40.0%, and 25.0%, respectively, of the patients with PVOM and in 28.6%, 28.6%, and 28.6%, respectively, with Tb VOM ( P0.01, P=0.59 and P=0.94). Neurologic deficit was seen in only 20% of patients with PVOM and 14.3% in Tb VOM ( P=0.74). In PVOM, the mean duration of antibiotics administration was 46.3 days. The percentage of patients that received surgical treatment was 40.0% in PVOM and 57.1% in Tb VOM. Conclusion: Time to diagnosis, presence of fever, and the age of the patients were factors that could aid in differentiating the etiology of VOM in children. Although MSSA and Tb were the most common pathogens in VOM, diverse causes of VOM exist; therefore efforts must be made to find the causative organism.