Paraplegia or paraparesis after operations on the thoracic and abdominal aorta is a devastating event, both for the patient and the surgeon. While its incidence varies from under 1% with operations at the top and bottom of the aorta, its occurrence in the midportion of the aorta, just above the diaphragm, even in the best of hands exceeds 10%. Over a decade ago, Crawford et al (J Vasc Surg. 1986;3:389–404) introduced the use of inclusion and sequential clamping techniques for thoracoabdominal aneurysmectomy, lowering both morbidity and neurologic sequelae. Although these techniques have been widely adopted, newer ancillary adjuncts have been recommended by a number of investigators. This paper summarizes the possible causes of paraplegia secondary to the various operations on the aorta and analyzes the status and value of the various ancillary techniques in its prevention.