Revisiting the Original Narakas Classification of Brachial Plexus Birth Injuries.

PURPOSE: Accurate classification of brachial plexus birth injury (BPBI) is critical for predicting outcomes and guiding early intervention. In 1987, Narakas introduced the first widely adopted system. Over time, misquotations and reinterpretations have obscured the work, conflating group definitions, exaggerating recovery rates, and misrepresenting prognosis.

METHODS

This manuscript revisits Narakas' original classification, traces misquotations, and clarifies their impact on management. We aim to provide the original publication as a reliable reference for contemporary care of BPBI.

RESULTS

Group 1 involves Sunderland grade 1-2 injuries to C5 and/or C6, with 93% achieving full spontaneous recovery. Group 2 includes Sunderland grade 2-3 injuries to C5-6 and grade 1-2 to C7. Groups 1 and 2 present similarly, with slightly weaker elbow extension in group 2. The key differentiator is slower recovery of the upper trunk, not C7 involvement. Only 22% fully recovered. Group 3 involves Sunderland grades 4-5 for C5-C6, grade 3 for C7, and grades 1-2 for C8-T1. Five percent achieved a full recovery, and 15% had a satisfactory outcome. Group 4 involves Sunderland grade 5 injuries to C5-C7 with avulsion of C8. No patients achieved full or good shoulder recovery, 35% had fair elbow recovery, and hand/wrist recovery was poor.

CONCLUSIONS

BPBI is complex, with extensive sequelae if mismanaged. Narakas' work provides critical guidance for prognosis and treatment. Misquotations have propagated inaccurate expectations and hindered care. Reprinting and disseminating the original classification and associated group outcomes clarifies prognosis, informs clinical decisions, and supports improved care. Our table and commentary provide an accessible reference to optimize BPBI care.

LEVEL OF EVIDENCE: IV.