We describe artificial openings in crania of the Early Iron Age nomads of the Lower Volga region, owned by the Moscow State University’s Research Institute and Museum of Anthropology. Such openings were found in two male specimens of the Sauromato-Sarmatian age from Bykovo (burial 4, kurgan 13) and Baranovka (burial 2, kurgan 21). Using macroscopic and X-ray examination, we attempt to identify the surgical techniques and the reasons behind the operations. The cranial vault of the Bykovo individual was trepanned by scraping and cutting, for medical purposes. The man survived the surgery, as evidenced by healing. In the case of Baranovka, the operation was performed postmortem or peri-mortem by drilling and cutting, possibly for ritual purposes. Collating these cases with others relating to the Early Iron Age nomadic (Sauromato-Sarmatian) culture of the Lower Volga region and adjacent territories and with written and archaeological sources suggests that the closest parallels come from Central Asia, and Southern and Western Siberia, where the custom of post-mortem ritual trepanations was very common. The surgical techniques practiced in the Lower Volga region were likely due to the penetration of Greek and Roman medical traditions in the mid-first millennium BC.