Purpose: There is a substantial gap in the scientific literature about specific, evidence-based guidelines for optimal word count (length) in multiple-choice question (MCQ) “stems” and “options” and validated time management strategies for MCQ test-takers. This dearth of research indicates a potential need for more studies to develop and validate these significant aspects of MCQ assessment and strategy. This was the first study which formulated guidelines for the word count of scenario-based MCQ (SB-MCQ) “stems” and “options,” along with justifications, from the perspective of medical education experts. The present research also developed specific, validated time management guidelines to assist test-takers effectively navigate MCQ examination. Methods: A mixed-methods design was implemented where quantitative data from a validated structured questionnaire and qualitative (focus group discussion) data were collected from 76 medical education professionals across multiple Indian provinces, and then analyzed using SPSS and NVivo software. Results: A recommended best practice for writing SB-MCQs was reported to have question stems between 35–50 words followed by 20–35 words, with three-option formats being preferred over four and five options. Nearly 92.73% of participants reported that, during 1-minute timeframe, maximum time must be spent on “analyzing question stem” followed by on “eliminating options.” The study developed succinct, “eight-step guide” to empower test-takers complete MCQ tests proficiently. Conclusion Scenario based MCQs with stems between 35–50 words and options between 1–10 words can improve item quality. Three-option MCQs can be preferred over four- or five-option formats. An emerged “eight-step structured guide” can assist test takers to tackle multiple-choice tests more efficiently and effectively.

Purpose: S1 pedicle screw loosening remains a significant challenge in lumbosacral fixation due to the unique anatomical and biomechanical properties of the sacrum. Traditional trajectories often face limitations, including poor screw hold and an elevated risk of complications. This study introduces the Vishal Peshattiwar (VP) trajectory for S1 pedicle screw placement, aiming to optimize screw positioning, improve construct stability, and reduce associated complications. Methods: A prospective analysis was conducted on 117 patients undergoing L5–S1 minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and multilevel MIS-TLIF including the L5–S1 level between June 2019 and August 2022. In total, 234 S1 pedicle screws were placed using the VP trajectory under O-arm-guided 3-dimensional computed tomography navigation. Screw parameters, including length, entry point, and angulation, were analyzed. Finite element analysis (FEA) was performed using Altair OptiStruct software to assess displacement forces and elemental stresses. Results: The average screw length was 45.90 mm in men and 44.88 mm in women. The caudocranial angle ranged from 50° to 65°, and the lateromedial angle from 18° to 25°. FEA demonstrated reduced displacement forces and elemental stresses, indicating improved construct stability. At a 2- to 4-year follow-up, complications were minimal, with 1 case of bilateral screw breakage and 1 dural tear. Conclusion The VP trajectory provides an improved approach for S1 screw placement, offering enhanced biomechanical stability, reduced complications, and better long-term outcomes. Its application is most effective with minimally invasive surgical techniques and navigation assistance.