BACKGROUND: Although cement augmentation of pedicle screws increases stability, complications, such as pulmonary embolism, must be considered. One possible approach to minimize complication risk is not augmenting all pedicle screws. It remains unclear whether full augmentation is necessary or if restricted cement augmentation is sufficient regarding cement-associated complications, implant failure, or adjacent fractures. RESEARCH QUESTION: Is there a difference in cement-associated complications, implant failure rate, and revision rates in non-cemented, fully augmented, and restricted cement-augmented long-segment posterior stabilization of the thoracolumbar spine? METHODS: In a single-center retrospective observational study, patients aged ≥60 years who underwent pedicle screw fixation of ≥3 segments in the thoracic/lumbar spine treating an osteoporotic fracture, metastatic lesion, or ankylosing spondylitis fracture were enrolled and categorized into no, full, and restricted cementation groups. Demographics, cement-associated complications, revision surgeries, implant failures, adjacent fractures, and other complications were also recorded. RESULTS: Cement leakage rate was significantly higher in the full than in the restricted cementation group (p <
0.05), with no sign of pulmonary embolism in either group. Patients with osteoporotic fractures experienced implant failure and adjacent fractures significantly more frequently than those with other pathologies (p <
0.05). In the full cementation group, the rate of screw cut-out with fractures of the last instrumented vertebra and adjacent fractures was the highest (p <
0.05). DISCUSSION AND CONCLUSION: Restricted cementation does not result in a higher rate of complications, particularly cement-associated complications, screw cut-out, or implant failure, and appears more favorable than full cementation.