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To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoraco-abdominal aneurysm repair (DTAAAR).Compared to euglycemia, hyperglycemia and ketosis make neurons respectively more vulnerable and more resilient to ischemia.During the study period (1997-2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, need for tracheostomy, de-novo dialysis, and survival) endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching.DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 non-diabetics. All preoperative variables had a standardized mean difference0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and operative mortality (14.1% vs. 6.0%, P 0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (OR 5.05, 95% CI 1.17 to 21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) (P 0.03). The results are summarized in the graphical abstract.DM is associated to increased operative mortality and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.