This prospective study compared the different clinical features and prognosis of two different types of sacral canal cysts (SESMC), treated with different surgical approaches. Sacral canal cysts were classified into two types based on the relationship between the cyst and the spinal nerve root fibers (SNRF) under the microscope: one type of cyst with spinal nerve root fibers, called Tarlov’s cyst, and the other type of cyst without spinal nerve root fibers. Depending on the type of sacral canal cyst, different surgical approaches are used. A modified Japanese Orthopedic Association (IJOA) scoring system was used to evaluate the neurological function status of patients before and after surgery. The preoperative IJOA score was 18.5±1.73 and the postoperative IJOA score was 19.6±0.78. The difference in IJOA scores before and after surgery was statistically significant (t=-4.52, p=0.0001), and the neurological function improved significantly after surgery. The most significant improvement was in neurological function (z=-2.74,p=0.006), followed by bowel/bladder function (z=-2.50, p=0.01). There was a statistically significant correlation between the type, number (F=12.57, p=0.001) and maximum diameter (F=8.08, p=0.006) of sacral cysts. Cysts with spinal nerve root fibers were usually multiple small cysts, whereas cysts without spinal nerve root fibers tended to be isolated and large. Given the significant clinical improvement after surgery, we advocate early surgical intervention for symptomatic sacral cysts. Surgical intervention is strongly recommended for both groups of patients with sacral duct cysts when they present with symptoms of neurological irritation and when neuroimaging reveals sacral erosion by the cyst. When a sacral cyst is found incidentally on physical examination, the patient should undergo annual review. Surgical treatment should be performed when the cyst gradually increases in size or when the patient becomes symptomatic. Our surgical technique follows the standard procedure for epidural spinal cyst surgery. An incision is made from L5 to S3 and the sacral lamina is completely exposed depending on the location of the cyst. The laminectomy is performed with a biting forceps while carefully protecting the integrity of the next layer of the cyst. The operation is performed under the surgical microscope. The terminal end of the dural sac is identified and the cyst is dissected out. The terminal sheath capsule is identified and dissected without covering cysts. Each cyst is dissected from the surrounding structures to reveal its origin and relationship to the nerve root fibers. If the cyst was identified as a nerve root fiber type, the cyst was partially excised and the defect was partially closed to prevent cerebrospinal fluid leakage and reconstruct the nerve root sheath. The excess cyst wall is reduced by bipolar cautery. If it is determined that the cyst is free of nerve root fibers and originates at the end of the axillary or terminal pool of the nerve root, the cyst neck is sutured, ligated, and the remaining cyst wall distal to the ligature is excised. If the cyst is associated with a tether, debridement of the tether is performed in the same procedure. Intraoperative neurophysiological monitoring was used to distinguish nerve root fibers from other tissues. The absence of motor nerve fiber involvement is confirmed with electrical stimulation. Local muscle flaps are reinforced for closure.