NCLEX · Reduction of Risk Potential

A nurse is caring for a client following a lumbar spinal fusion. The client reports sudden onset of severe leg pain and is unable to move their toes. What is the PRIORITY action?

Correct answer

Immediately notify the surgeon — new neurological deficit (inability to move toes) and severe leg pain following spinal surgery may indicate spinal cord compression from haematoma or hardware failure; this is a surgical emergency with a narrow window for intervention

  1. A Administer a PRN analgesic per order
  2. B Immediately notify the surgeon — new neurological deficit (inability to move toes) and severe leg pain following spinal surgery may indicate spinal cord compression from haematoma or hardware failure; this is a surgical emergency with a narrow window for intervention
  3. C Reposition the client and reassess in 30 minutes
  4. D Order a urinalysis to check for infection

Why this is the answer

POST-SPINAL SURGERY NEUROLOGICAL DETERIORATION is a surgical emergency. NEW ONSET OF MOTOR DEFICIT (inability to move toes) in a post-laminectomy or spinal fusion patient is NEVER normal — it requires IMMEDIATE assessment and intervention. POSSIBLE CAUSES: EPIDURAL HAEMATOMA — blood collects in the epidural space and compresses the spinal cord; most common cause of post-spinal surgery neurological deficit; WINDOW FOR INTERVENTION: neurological function can often be preserved if decompressive surgery occurs within 4-6 hours of onset; beyond this window, deficits may become permanent; HARDWARE COMPLICATION — screw or cage malpositioning; OEDEMA — surgical site oedema compressing neural structures. WHAT NOT TO DO: Do NOT administer analgesics and re-assess — the pain and neurological deficit require immediate evaluation, and analgesics may mask the assessment; Do NOT assume it's normal post-operative discomfort — motor deficit is NEVER within normal range post-operatively; Do NOT wait — the speed of surgical decompression determines whether function can be preserved. NURSING ASSESSMENT TO REPORT: Exact onset time; baseline neurological assessment before surgery (what was normal for this patient?); current motor, sensory, and bowel/bladder function; vital signs; pain characteristics; AFTER NOTIFICATION: Prepare for emergency imaging (MRI or CT myelogram); possible emergency return to OR.
Source: NCLEX-RN Physiological Integrity — Post-Spinal Surgery Neurological Emergency