The management of sacral tumors warrants a dedicated discussion due to the unique skeletal, neurologic, vascular, soft tissue, and colorectal considerations of this anatomic region. It is critical to approach treatment comprehensively based on an understanding of tumor characteristics, surgical and nonsurgical treatment outcomes, and salvage options. Optimal outcomes depend on close multidisciplinary collaboration with radiation oncology, interventional radiology, other surgical specialties, rehabilitation, and pain management teams. Patient-centered decision-making is crucial, as treatments can be life-altering, and the potential for complications is high. The treatment of primary sacral tumors is focused on disease control and potential cure while balancing treatment morbidity. In metastatic disease to the sacrum, the focus is on palliation, and treatment-related morbidity should be avoided. Outcomes are optimized by multidisciplinary engagement with tumor control, reconstruction, and rehabilitation.