<p>The optimal management of spondylodiscitis is still controversial. Large spectrum or targeted antibiotic therapy is the first option in neurologically intact patients, while surgery is reserved for cases of intractable pain, acute neurological defects and bone destruction-related spinal instability. Treatment failure due to lack of diagnosis may lead to infection persistence and progression, causing patients to shift from the medical to the surgical arm. In a 10 years’ time, we treated 84 patients affected by primary spontaneous pyogenic spondylodiscitis. Forty-two patients underwent antibiotic therapy alone, 42 posterior fixation/decompression and disc debridement. At admission, we assessed all patients for neurological deficits and pain intensity, using appropriate imaging to rule out instability/neural compression. We compared the two groups in terms of pain control, mobilization, length of hospital stay, antibiotic therapy, and complications. Patients undergoing surgical treatment presented significantly shorter hospital stay, earlier and better pain control, faster mobilization from bed, shorter use of brace and shorter antibiotic therapy courses. No major complications occurred in both groups, while one revision was performed due to wound failure. In agreement with our results, posterior vertebral decompression and fixation should be considered a viable option in cases of spondylodiscitis with severe pain and/or neurological impairment. The operated patients fared clinically well (despite starting from worse clinical conditions than their medical counterparts) and the complication rate was negligible.</p>