Primary malignant sacral tumors are a rare entity and usually require en bloc resection for local control. To avoid injury of the presacral viscera and vessels, most centers adopted a combined anterior/posterior approach to perform sacrectomy above S3 level in a one-stage or two-stage setting, which had been justified for its safety and efficacy but were time-consuming and at risk of massive bleeding. However, we have previously reported the experience of total en bloc sacrectomy via a posterior-only approach that could significantly decrease operative time and hemorrhage. Indications for total en bloc sacrectomy using a posterior approach in our center were as follows: (1) primary malignant sacral tumor involving at least S1–2; (2) tumor not involving the internal iliac vessels and bowel, based on imaging studies and digital rectal examination; and (3) recurrent sacral tumor in patients who had not previously undergone an anterior procedure.