Purpose of review <p>Spinal cord ischemia remains the Achilles heel of aortic surgery. This review examines our understanding of the etiology of spinal cord ischemia, including up-to-date prevention strategies.</p> Recent findings <p>Despite improvement in understanding the etiology of spinal cord ischemia a paucity of novel interventions for prevention have been developed. However, revascularization of the hypogastric and subclavian arteries, staged repair and protocolized implementation of physiologic maneuvers can reduce the risk of spinal cord ischemia.</p> Summary <p>Knowledge and implementation of these prevention strategies is critical to reduce the incidence of spinal cord ischemia.</p>