Perineural spread is an important yet relatively under-recognized imaging manifestation of abdominal and pelvic diseases, most commonly of neoplastic origin. Its detection can be challenging, as imaging findings are often subtle, but a thorough understanding of relevant anatomy and neural pathways, greatly improves diagnostic accuracy. Identifying PNS carries significant prognostic implications and can directly influence patient management. Early recognition is therefore critical for both optimizing oncologic outcomes and improving patient quality of life.