BACKGROUND CONTEXT While advances have been made in the surgical management of distal junctional kyphosis (DJK), complication rates remain high. Although individual factors related to its occurrence have been cited, many of these cases are mild and have no clinical relevance nor have these been combined into a formal predictive model, particularly for cases that are clinically impactful. PURPOSE Develop a formal predictive model distinguishing between symptomatic and asymptomatic DJK. STUDY DESIGN/SETTING Retrospective review PATIENT SAMPLE A total of 99 cervical deformity patients (CD) with 1 year (1Y) follow up OUTCOME MEASURES Complications; reoperations; HRQL, alignment METHODS CD patients (pts) were stratified into asymptomatic (Asym) and symptomatic (Sym) DJK. DJK angle (DJKA) was defined >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Asym: ∆DJK to be>10° in the absence neurologic sequelae. Sym: 1) DJKA> 10° and either reop due to DJK or >one new-onset neurological sequelae related to DJK or 2) pts who had either a DJKA > 20° or ∆DJKA > 20°. Stepwise logistic regressions were used to identify patient-specific, surgical, radiographic and HRQL factors that were associated with these types of DJK. Decision tree analysis established cut-offs for the continuous variables. RESULTS A total of 99 CD pts were included (60yrs, 26.5kg/m2, 66.7%F). Surgical characteristics: 7.4±4 levels fused, 47.5% posterior, 18.2% anterior, and 34.3% combined. Overall, 32.2% developed DJK (34.3% Asym, 65.7% Sym). 37.5% of Asym pts received a reop vs 62.5% Sym pts. At BL, Asym pts had a greater BMI (28.5 vs 23kg/m2) and NSR back pain (5.2 vs 4.6; all p 0.65, UIV cephalad to C2, and C2-C7 apex caudal to C5. Multivariate analysis identified independent radiographic and surgical factors for developing Sym DJK: [Radiographic] BL PI (1.02[0.9-1.07]), preop cervical flexibility (1.04[1.01-1.07]); [Surgical] combined approach (6.2[1.4-27]; all p 7 levels fused (AUC: 0.89). A predictive model for Sym versus Asym pts yielded an AUC of 85% and included being frail, having a TS-CL>20, and a PI>46.3. Controlling for BL deformity and disability, Sym pts had greater cSVA(4-8cm: 47.6%vs 27%) and were more maligned according to their SRS-SVA (0.1[0.76-0.02]) than non DJK pts at 1Y (all p CONCLUSIONS Overall 32.2% cervical deformed patients suffered from DJK most of which were clinically significant. Severe symptomatic DJK can be predicted with high reliability using combined determinants of baseline spinal cord dysfunction, mobility, frailty, and surgical factors including end levels, number of levels fused and use of a combined approach. It can be further distinguished from asymptomatic occurrences by taking into account pelvic incidence and baseline cervicothoracic deformity severity. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.