Aim:To evaluate the efficacy of surgical interventions for pediatric lumbosacral lipomas (LSL) by focusing on preoperative symptoms, postoperative outcomes, and long-term prognosis. Additionally, we aimed to analyze the impact of different LSL types on surgical strategy and patient recovery.Material and Methods:The medical records and magnetic resonance images (MRI) of 28 pediatric patients (15 boys and 13 girls aged 1–17 years) who underwent LSL resection between 2018 and 2023 were retrospectively reviewed. The study assessed surgical indications, techniques (including using neuromonitoring and the extent of lipoma resection), and postoperative management. The LSLs were classified based on their location and relationship with the spinal cord, which informed the surgical approaches and prognostic predictions. Outcome measures included neurological function, as assessed by the Hoffmann grading system, and complications such as wound dehiscence and cerebrospinal fluid leakage.Results:The dorsal LSLs demonstrated a 62.5% total resection rate with 37.5% symptomatic improvement after surgery. The caudal LSLs demonstrated a lower total resection rate (46.15%), with 30.77% of the patients experiencing symptom worsening. Transitional LSLs demonstrated a 100% positive outcome after total resection. Chaotic LSLs, the most complex LSL, had a postoperative deterioration rate of 40% after subtotal resection. Overall, surgical complications were noted in 17.8% of the patients.Conclusion:Surgical management of symptomatic pediatric patients with LSL yields significant benefits, with a careful balance between radical resection and preservation of neurological function. The type of lipoma significantly influences surgical planning and outcomes. Despite challenges in achieving complete resection in chaotic LSLs, tailored surgical approaches based on preoperative imaging and lipoma classification can optimize patient outcomes.