Spinal cord ischemia (SCI) is one of the most feared complications after treatment of thoracic aortic diseases. Based on limited evidence from clinical trials of investigational devices the incidence appears to be lower in endovascular compared to open thoracic aortic repairs. To date, several clinical and procedural factors have been associated with an increased risk of SCI, including the type of aortic pathology, length of endograft coverage, and perioperative hypotension. The treatment options mostly consist of spinal fluid drainage and systemic blood pressure elevation in an effort to maximize spinal cord perfusion. In this article, we review the risk factors for development of SCI, some diagnostic tests that may allow for its earlier detection, and potential strategies for its prevention.