One hundred twenty (n=120) patients with lumbar disc herniation (LDH) were randomized to receive PTED guided by a 3D visualization virtual surgery system combined with a self-made intervertebral foramen positioning puncture device (3DVVSS + IFPPD) (n = 60) or traditional freehand PTED (n = 60). The primary outcome of interest was the number of puncture attempts. Secondary outcomes included puncture time, fluoroscopy times, operation time, and postoperative functional scores (VAS and ODI). Outcomes were assessed at baseline, 1 day postoperatively, and 6 months postoperatively. The 3DVVSS + IFPPD group showed significantly fewer puncture attempts, shorter puncture and operation times, and reduced fluoroscopy exposure, although both groups demonstrated similar improvements in pain and disability scores over time.