The presacral space is a clinically important space that is relevant to multiple disciplines and lies at the intersection of the axial skeleton, neural axis, and pelvic soft tissues. A wide variety of benign and malignant conditions may derive from its various elements. An appropriate differential diagnosis may be formulated from a more comprehensive list by considering the specific imaging features of a given case: In particular, involvement of the sacrum (either remodeling or destruction) and the presence or absence of a solid, soft-tissue component may help narrow the differential diagnosis. Typically, osteochondral and neurogenic tumors remodel or destroy the sacrum, whereas sacral involvement is less common in patients with a mesenchymal tumor. Ewing sarcomas and chordomas are typically associated with a large soft-tissue mass. Demographic features are also important: Typically, congenital and developmental tumors occur in younger patients, and chondrosarcomas occur in older patients (mean age, 45 years). Finally, specific imaging features may help establish the diagnosis. For instance, an osseous or chondroid matrix is indicative of osteosarcoma or chondrosarcomas; neurofbromas may have a target appearance at magnetic resonance (MR) imaging; hemangiomas have areas of increased signal intensity on T1-weighted MR images, a result of fat and hemorrhage; and myeloplipomas contain macroscopic fat.