Sixty-eight patients with lumbar disc herniation were randomized to biplane ultrasound guidance (US) (n=34) or fluoroscopy (n=34) for percutaneous lumbar intervertebral foramen insertion (PLIFI), with a prespecified learning-curve split yielding a proficiency subset (n=23) for the US arm. The primary outcomes were first-attempt success, number of puncture adjustments, number of radiographs, puncture time, and operator confidence; secondary outcomes included operative time, complications, pain/disability scores, and satisfaction up to 3–6 months (procedure-dependent). Overall, the results of the study revealed that at proficiency, biplane US increased first-attempt success, reduced fluoroscopies, decreased puncture time, and required fewer adjustments, with similar clinical outcomes and no puncture-related complications. In short, biplane US provided a faster, more accurate, and lower-radiation workflow for PLIFI once basic proficiency was achieved.