The Effect of Adding Magnesium Sulfate to Standard Epidural and Interscalene Block in Treatment of Patients With Chronic Pain

N-methyl-D-aspartate(NMDA) receptors are fundamental factors in controlling synaptic
plasticity and memory function and play an important role in transition of acute pain to
chronic intractable pain.

Magnesium is physiologic NMDA receptor antagonist. It will stabilized NMDA receptor and
prevents influx of calcium and sodium ion. It has been studied that serum magnesium level is
low in patients with chronic pain. Several studies has been done and shown that Magnesium
has a significant effect in neuroprotection and membrane stabilization. Blocking the NMDA
receptor will prevent activation of first order neurons in periphery or second order neurons
in dorsal horn of spinal cord and then higher pain pathways to third order neurons and
centers of the pain perception. Topical, oral and more effectively intravenous
administration of magnesium has been used widely in treatment of chronic pain. There are
limitations of intravenous administration of magnesium secondary to systemic cardiovascular
side effects.

In several standardized study it has been shown that using magnesium intrathecally,
epidurally or with interscalene injections can boost up the effect of opioids or local
anesthetics. At the dose of 100 mg, it has been safe and effective to use.

Regional anesthesia is a safe, inexpensive technique, with the advantage of prolonged pain
relief.

In the pain clinic the investigators perform different injections as the standard treatment
for chronic pain based on the diagnosis and indications. Local anesthetic like Bupivacaine
with or without Steroids (Depo-medrol) is used for these injections.

The investigators' goal is comparing pain control in different groups adding the magnesium
sulfate 100mg to our compounds as an inexpensive, effective, and safe adjuvant to prolong
the duration of analgesia and reduce the amount of narcotic dose. The investigators want to
conduct a prospective, randomized, double-blind placebo controlled study with two major
injections (2 different studies with the same concept):

1. Interscalene injection (2 subgroups including A: with Bupivacaine 0.25%(20ml) which is
the standard injection with 1ml saline as placebo vs B: Bupivacaine 0.25%(20ml)+
Magnesium sulfate (100mg in 1 ml)

2. Epidural injection(2 subgroups including A:Bupivacaine 0.125%(8ml)+ Depo medrol(80mg)
as the standard injection with 1ml saline as placebo vs B: Bupivacaine 0.125%(8ml)+
Depo medrol(80mg)+ Magnesium sulfate (100mg in 1 ml)

Inclusion Criteria:

- Patients must be 18 yrs of age and older

- Minimal level of pain of equal or higher than 4 out of 10 on Numerical Rating
Scale(NRS=>4)

- The rest of inclusion criteria are based on pain clinic protocols for regular
injections

Exclusion Criteria:

- Pregnant patients

- Children

- The rest of exclusion criteria are based on pain clinic protocols for regular
injections