Presacral tumors are a heterogeneous group of tumors with a predominance of the tumors being congenital in origin and the remainder being neurogenic, osseous, or miscellaneous in origin. These tumors should be removed surgically as fully a third of them may be malignant and benign lesions can undergo malignant transformation. The diagnosis of these tumors is often delayed because of vague symptomatology, and often these lesions are advanced when found. MRI is essential for surgical planning. Complete resection is critical for these lesions as it drives the outcomes and prognosis for these patients.