Purpose <p>This study aimed to investigate the predictive performance of S₁ vertebral Hounsfield unit (HU) values and S₁ vertebral bone quality (VBQ) scores for new vertebral compression fractures (NVCF) after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fractures (OVCF).</p> Methods <p>This retrospective analysis included patients who underwent PKP in our hospital from 2016 to 2024, categorizing them into non-NVCF and NVCF groups. The T₁₂–L₂ HU value, S₁ HU value, L₁–L₄ VBQ score, and S₁ VBQ score were collected from preoperative CT and MRI, respectively. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the predictive performance of these parameters.</p> Results <p>This study included 314 patients, of whom 107 (34.1%) developed NVCF during the follow-up period. Statistically significant differences in the T₁₂–L₂ HU value (<i>P</i> &lt; 0.001), S₁ HU value (<i>P</i> &lt; 0.001), L₁–L₄ VBQ score (<i>P</i> &lt; 0.001), and S₁ VBQ score (<i>P</i> &lt; 0.001) were observed between the two groups. Multivariable analysis revealed that NVCF was independently associated with T₁₂–L₂ HU value (OR = 0.96, 95% CI = 0.95–0.97, <i>P</i> &lt; 0.001), S₁ HU value (OR = 0.98, 95% CI = 0.97–0.98, <i>P</i> &lt; 0.001), L₁–L₄ VBQ score (OR = 2.24, 95% CI = 1.70–2.96, <i>P</i> &lt; 0.001), and S₁ VBQ score (OR = 3.39, 95% CI = 2.36–4.48, <i>P</i> &lt; 0.001). ROC analysis revealed an adjusted area under the curve (AUC) of 0.773 (optimal cut-off: 3.33; sensitivity: 79.4%; specificity: 56.0%) and 0.808 (optimal cut-off: 92.91; sensitivity: 80.7%; specificity: 66.4%) for the S₁ VBQ score and S₁ HU value, respectively. Furthermore, the adjusted AUC for the T₁₂–L₂ HU value and L₁–L₄ VBQ score were 0.825 and 0.773, respectively.</p> Conclusion <p>The S₁ HU value and S₁ VBQ score were considered independent predictors of NVCF after PKP. The S₁ HU value is the most clinically useful indicator, the S₁ VBQ score serves as a supplementary indicator.</p>