The Accuracy and Challenges of Virtopsy for Age Estimation: A Systematic review & Meta-Analysis in Forensic and Medico-Legal Investigation

Background: Virtopsy, a non-invasive imaging method employing CT, MRI, and PMCT (post-mortem computed tomography), is increasingly applied in forensic age estimation. However, concerns about accuracy, reproducibility, and methodological inconsistencies persist. Objective: To assess the accuracy, reliability, and population-specific variability of Virtopsy-based age estimation methods across multiple anatomical sites and imaging modalities. Methods: A systematic review following PRISMA guidelines included 14 studies conducted between 2015 and 2025, identified through comprehensive searches of PubMed, ScienceDirect, Scopus, and Web of Science. Quality assessments were performed using QUADAS-2. Data on imaging modalities, anatomical landmarks, diagnostic metrics, and reliability were synthesized. A random-effects meta-analysis was conducted to pool diagnostic accuracy and mean absolute error (MAE), while subgroup analyses explored variability across populations, anatomical sites, developmental stages, and gender. Results: Pooled accuracy was 77.01%, with the highest performance in clavicle-based assessments (accuracy: 90%, MAE: 1.94 years). Gender-specific analysis revealed slightly stronger correlations in males (r = 0.887) compared to females (r = 0.870). Internal reliability was high (κ> 0.7), while external reliability varied due to methodological heterogeneity. Subgroup analyses revealed reduced accuracy in older populations and notable variability across skeletal markers and developmental stages. Conclusion: Virtopsy demonstrates strong potential for age estimation, particularly in adolescent populations. Challenges include anatomical variability, protocol inconsistency, and reduced accuracy in older subjects. Standardization and integration of AI-assisted protocols may improve its forensic utility.