68 year old man presented with difficulty with manual dexterity, as well as numbness and tingling in the L.hand 5 years before. One year later the same symptoms developed in the R.hand and about 3 years later he felt clumsiness in the legs,  and gait imbalance.Examination showed normal mental status and cranial nerves. There was weakness (4/5) of L. finger and wrist extension, bilateral thumb abduction, and bilateral finger abduction. Reflexes were absent throughout. Sensory exam showed absent vibration and impaired proprioception in the L.fingers, , vibration was also diminished at the L.big toe. The gait was normal. Click here for EMG and nerve conduction study.