PurposeResidual back pain (RBP) after percutaneous vertebral augmentation (PVA) still exists considerable, and it even affects daily life due to moderate or severe back pain. A variety of risk factors have been previously identified for developing residual back pain. However, there are conflicting reports regarding the association between sarcopenia and residual back pain. As such, the aim of this study was to investigate whether paraspinal muscle fatty degeneration is a predictor of residual back pain.MethodsWe retrospectively reviewed the medical records of patients with single-segment OVCF who underwent PVA from January 2016 to January 2022. Patients were divided into RBP group (86 patients) and control group (790 patients) according to whether the visual analog scale (VAS) score ≥ 4. The clinical and radiological data were analyzed. Paraspinal musculature fatty degeneration was measured using the Goutallier classification system (GCS) at the L4 − 5 intervertebral disc level. Univariate and multivariate logistic regression analyses were performed to identify risk factors.ResultsThe results of multivariate logistical regression analysis revealed that posterior fascia injury (odds ratio (OR) = 5.23; 95% confidence interval (CI) 3.12–5.50;P< 0.001), as regards paraspinal muscle fatty degeneration, including Goutallier grading (OR= 12.23; 95%CI7.81–23.41;P< 0.001), fCSA (OR= 3.06; 95%CI1.63–6.84;P= 0.002), fCSA/CSA (%) (OR= 14.38; 95%CI8.80–26.29;P< 0.001), and facet joint violation (OR= 8.54; 95%CI6.35–15.71;P< 0.001) were identified as independent risk factors for RBP.ConclusionsPosterior fascia injury, paraspinal muscle fatty degeneration, and facet joint violation were identified as independent risk factors for RBP, with paraspinal muscle fatty degeneration playing an important role.